Provider Demographics
NPI:1902878689
Name:ANGELUS ANESTHESIA LTD
Entity Type:Organization
Organization Name:ANGELUS ANESTHESIA LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CRNA
Authorized Official - Prefix:
Authorized Official - First Name:JOANN
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-368-8118
Mailing Address - Street 1:PO BOX 1745
Mailing Address - Street 2:
Mailing Address - City:LAKESIDE
Mailing Address - State:AZ
Mailing Address - Zip Code:85929-1745
Mailing Address - Country:US
Mailing Address - Phone:928-368-8118
Mailing Address - Fax:928-368-8121
Practice Address - Street 1:2200 E SHOW LOW LAKE RD
Practice Address - Street 2:
Practice Address - City:SHOW LOW
Practice Address - State:AZ
Practice Address - Zip Code:85901-7881
Practice Address - Country:US
Practice Address - Phone:928-368-8118
Practice Address - Fax:928-368-8121
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-06
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ497843Medicaid
AZZ71267Medicare PIN