1295711430 NPI number — MR. LARRY C WHEEKER RN, CRNA

Table of content: MR. LARRY C WHEEKER RN, CRNA (NPI 1295711430)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295711430 NPI number — MR. LARRY C WHEEKER RN, CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WHEEKER
Provider First Name:
LARRY
Provider Middle Name:
C
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
RN, CRNA
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1295711430
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/23/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1900 WOODLAND DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COOS BAY
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97420-0000
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-267-5151
Provider Business Mailing Address Fax Number:
541-266-4501

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1900 WOODLAND DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COOS BAY
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97420-0000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-267-5151
Provider Business Practice Location Address Fax Number:
541-266-4501
Provider Enumeration Date:
12/20/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 367500000X , with the licence number:  200160039CRNA , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 268921 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: R0000WFBTV . This is a "MEDICARE GROUP PIN NUMBER" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 079044214RN . This is a "RN LICENSE #" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 1407812365 . This is a "NBMC GROUP NPI NUMBER" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 430069427 . This is a "RR MEDICARE PTAN NUMBER" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: CD8723 . This is a "RR MEDICARE GROUP NUMBER" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 031589 . This is a "CRNA RECERTIFICATION #" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".




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