Provider Demographics
NPI:1174566277
Name:WESTERN ANESTHESIA ASSOCIATES LLC
Entity type:Organization
Organization Name:WESTERN ANESTHESIA ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:E.
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:LARSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-299-2160
Mailing Address - Street 1:PO BOX 3810
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84110-3810
Mailing Address - Country:US
Mailing Address - Phone:801-527-3841
Mailing Address - Fax:801-733-5618
Practice Address - Street 1:630 MEDICAL DR
Practice Address - Street 2:
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010-4908
Practice Address - Country:US
Practice Address - Phone:801-299-2160
Practice Address - Fax:801-299-2549
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-14
Last Update Date:2009-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT=========001Medicaid
UT000057828Medicare ID - Type Unspecified