Provider Demographics
NPI:1528649183
Name:MALDONADO HEVIA, JOSE L (CRNA)
Entity type:Individual
Prefix:
First Name:JOSE
Middle Name:L
Last Name:MALDONADO HEVIA
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:930 PACIFIC HILLS PT APT B106
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80906-8448
Mailing Address - Country:US
Mailing Address - Phone:939-244-9868
Mailing Address - Fax:
Practice Address - Street 1:1008 MINNEQUA AVE
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81004-3733
Practice Address - Country:US
Practice Address - Phone:800-228-4039
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-15
Last Update Date:2021-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VI12996364SC0200X
CO0996440367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No364SC0200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistCritical Care Medicine