Provider Demographics
NPI:1316958416
Name:PATTERSON, PRISCILLA (CRNA)
Entity type:Individual
Prefix:
First Name:PRISCILLA
Middle Name:
Last Name:PATTERSON
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 HUNTINGTON BEACH DR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80921-3228
Mailing Address - Country:US
Mailing Address - Phone:719-433-6221
Mailing Address - Fax:
Practice Address - Street 1:NA
Practice Address - Street 2:
Practice Address - City:NA
Practice Address - State:NA
Practice Address - Zip Code:00000
Practice Address - Country:UM
Practice Address - Phone:000-011-1111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-11
Last Update Date:2013-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX616626367500000X
CO66596367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO66021880Medicaid
COCOA109660Medicare PIN