Provider Demographics
NPI:1053603993
Name:PITCHFORTH, CLINT B (CRNA)
Entity type:Individual
Prefix:
First Name:CLINT
Middle Name:B
Last Name:PITCHFORTH
Suffix:
Gender:M
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:PO BOX 10100
Mailing Address - Street 2:
Mailing Address - City:DELTA
Mailing Address - State:CO
Mailing Address - Zip Code:81416-0008
Mailing Address - Country:US
Mailing Address - Phone:970-874-7681
Mailing Address - Fax:970-874-6400
Practice Address - Street 1:1501 E 3RD ST
Practice Address - Street 2:
Practice Address - City:DELTA
Practice Address - State:CO
Practice Address - Zip Code:81416-2815
Practice Address - Country:US
Practice Address - Phone:970-874-7681
Practice Address - Fax:970-874-6400
Is Sole Proprietor?:No
Enumeration Date:2011-05-11
Last Update Date:2021-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCRNA-01147367500000X
AZ250160367500000X
CO100093367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ634497Medicaid
UT1053603993Medicaid
CO25670875Medicaid
NM69837252Medicaid
NMNMAAA1472OtherMEDICARE PTAN