Basic Information
| Provider Information | |||||||||
| NPI: | 1194210328 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | VILLA ANESTHESIA PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 742 S DAVID ST | ||||||||
| Address2: | |||||||||
| City: | CASPER | ||||||||
| State: | WY | ||||||||
| PostalCode: | 826013137 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3072349657 | ||||||||
| FaxNumber: | 3072340306 | ||||||||
| Practice Location | |||||||||
| Address1: | 1233 E 2ND ST | ||||||||
| Address2: | |||||||||
| City: | CASPER | ||||||||
| State: | WY | ||||||||
| PostalCode: | 826012926 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3075777201 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2018 | ||||||||
| LastUpdateDate: | 06/29/2018 | ||||||||
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| AuthorizedOfficialLastName: | HARDY | ||||||||
| AuthorizedOfficialFirstName: | MARGUERITE | ||||||||
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| AuthorizedOfficialTitleorPosition: | AUTHORIZED OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 3072349657 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | TL4408 | WY | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 1407913270 | 05 | IL | MEDICAID |