Basic Information
| Provider Information | |||||||||
| NPI: | 1831305036 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PUEBLO ANESTHESIA & PAIN SERVICES | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12 PAJARITO LOOP | ||||||||
| Address2: | |||||||||
| City: | SANTA FE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875067217 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5736865550 | ||||||||
| FaxNumber: | 5736862139 | ||||||||
| Practice Location | |||||||||
| Address1: | 3917 WEST RD | ||||||||
| Address2: | |||||||||
| City: | LOS ALAMOS | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875442275 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5736865550 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2007 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | EVANS | ||||||||
| AuthorizedOfficialFirstName: | STEVEN | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 5736865550 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | NM | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 207LP3000X | NM | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | Pediatric Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 613133000 | 01 | NM | DOL | OTHER | NM007F15 | 01 | NM | BCBS | OTHER | 50333259 | 05 | NM | MEDICAID |