Organization
WOODLAND PARK ANESTHESIA LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
LONNIE W CLARK (PRESIDENT)
(806) 790-3928
Entity
Organization
Contact information
Practice address
16420 W US HIGHWAY 24, WOODLAND PARK, CO 80863-8760
(719) 687-9989
Mailing address
PO BOX 9040, WOODLAND PARK, CO 80866-9040
(719) 900-3960
Taxonomy
Speciality
Code
Description
License number
State
367500000X
Certified Registered Nurse Anesthetist
Primary
—
CO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
09932275
—
CO
01
—
COAAA0139
MEDICARE PTAN
CO
Enumeration date
05/03/2011
Last updated
12/10/2020
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