Provider Demographics
NPI:1194770768
Name:OLD PUEBLO ANESTHESIA
Entity type:Organization
Organization Name:OLD PUEBLO ANESTHESIA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:KRISTY
Authorized Official - Middle Name:
Authorized Official - Last Name:FRESH
Authorized Official - Suffix:
Authorized Official - Credentials:HCM, MBA, FACMPE, LS
Authorized Official - Phone:520-324-2030
Mailing Address - Street 1:2810 N SWAN RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85712-6300
Mailing Address - Country:US
Mailing Address - Phone:520-324-2030
Mailing Address - Fax:520-445-6019
Practice Address - Street 1:2810 N SWAN RD
Practice Address - Street 2:SUITE 100
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712-6305
Practice Address - Country:US
Practice Address - Phone:520-324-2030
Practice Address - Fax:520-445-6019
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-23
Last Update Date:2020-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ096736Medicaid
AZ096736Medicaid