Provider Demographics
NPI:1104083344
Name:AGNOLETTO ANESTHESIA , INC
Entity type:Organization
Organization Name:AGNOLETTO ANESTHESIA , INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SALLY
Authorized Official - Middle Name:K
Authorized Official - Last Name:AGNOLETTO
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:303-422-9438
Mailing Address - Street 1:PO BOX 2994
Mailing Address - Street 2:
Mailing Address - City:EDWARDS
Mailing Address - State:CO
Mailing Address - Zip Code:81632-2994
Mailing Address - Country:US
Mailing Address - Phone:303-422-9438
Mailing Address - Fax:303-422-9474
Practice Address - Street 1:100 W BEAVER CREEK BLVD
Practice Address - Street 2:
Practice Address - City:AVON
Practice Address - State:CO
Practice Address - Zip Code:81620
Practice Address - Country:US
Practice Address - Phone:303-422-9438
Practice Address - Fax:303-422-9474
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-16
Last Update Date:2008-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO95481367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
COC1336Medicare PIN