Basic Information
| Provider Information | |||||||||
| NPI: | 1548401789 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | GATEWAY ANESTHESIA LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 400 E 10TH ST | ||||||||
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| City: | WACONIA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553874552 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9524429770 | ||||||||
| FaxNumber: | 9524423630 | ||||||||
| Practice Location | |||||||||
| Address1: | 1025 NE GATEWAY CT | ||||||||
| Address2: | |||||||||
| City: | CONCORD | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280252440 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7049207020 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/18/2009 | ||||||||
| LastUpdateDate: | 01/23/2013 | ||||||||
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| AuthorizedOfficialLastName: | BASHORE | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 7047796861 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | NC | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.