Provider Demographics
NPI:1083131445
Name:ACEBO, SAMUEL ANDERS (MSN, CRNA)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:ANDERS
Last Name:ACEBO
Suffix:
Gender:M
Credentials:MSN, CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5040
Mailing Address - Street 2:
Mailing Address - City:OROVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95966-0040
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2767 OLIVE HWY
Practice Address - Street 2:
Practice Address - City:OROVILLE
Practice Address - State:CA
Practice Address - Zip Code:95966-6118
Practice Address - Country:US
Practice Address - Phone:530-532-8472
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-26
Last Update Date:2017-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95000762367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty