Basic Information
| Provider Information | |||||||||
| NPI: | 1740275924 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CARMEN | ||||||||
| FirstName: | LORI | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1000 CORDOVA PL | ||||||||
| Address2: | # 712 | ||||||||
| City: | SANTA FE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875051725 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5057478639 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1010 SPRUCE ST | ||||||||
| Address2: | |||||||||
| City: | ESPANOLA | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875323456 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5057537111 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2005 | ||||||||
| LastUpdateDate: | 02/05/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | R47417 | NM | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 430074229 | 01 | NM | RAILROAD MEDICARE INDIVID | OTHER | NM006426 | 01 | NM | BCB NM - INDIVIDUAL | OTHER | 17104505 | 05 | NM | MEDICAID |