Basic Information
Provider Information
NPI: 1235400318
EntityType: 2
ReplacementNPI:  
OrganizationName: SONOMA AMBULATORY ANESTHESIA GROUP, INC.
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: PO BOX 4860
Address2:  
City: MURRELLS INLET
State: SC
PostalCode: 295762698
CountryCode: US
TelephoneNumber: 8436512624
FaxNumber: 8433574940
Practice Location
Address1: 1210 SONOMA AVE
Address2: STE. B
City: SANTA ROSA
State: CA
PostalCode: 954056648
CountryCode: US
TelephoneNumber: 7075712192
FaxNumber: 8433574940
Other Information
ProviderEnumerationDate: 01/20/2012
LastUpdateDate: 01/20/2012
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: MITCHELL
AuthorizedOfficialFirstName: MICHAEL
AuthorizedOfficialMiddleName: T.
AuthorizedOfficialTitleorPosition: BUSINESS MANAGER
AuthorizedOfficialTelephone: 8436512624
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
367500000XC3255198CAY193400000X MULTIPLE SINGLE SPECIALTY GROUPPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered 

No ID Information.


Home