Basic Information
| Provider Information | |||||||||
| NPI: | 1750710778 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTH LAKE ANESTHESIA SERVICES, P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1381 CITRUS TOWER BLVD | ||||||||
| Address2: | SUITE 4 | ||||||||
| City: | CLERMONT | ||||||||
| State: | FL | ||||||||
| PostalCode: | 347111957 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3522439114 | ||||||||
| FaxNumber: | 3522437822 | ||||||||
| Practice Location | |||||||||
| Address1: | 1099 CITRUS TOWER BLVD | ||||||||
| Address2: | |||||||||
| City: | CLERMONT | ||||||||
| State: | FL | ||||||||
| PostalCode: | 347111947 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3523944071 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/12/2013 | ||||||||
| LastUpdateDate: | 11/12/2013 | ||||||||
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| AuthorizedOfficialLastName: | CONNOR | ||||||||
| AuthorizedOfficialFirstName: | BRIAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 3522439114 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.