1639164742 NPI number — SHERILYN R WETER CRNA

Table of content: SHERILYN R WETER CRNA (NPI 1639164742)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639164742 NPI number — SHERILYN R WETER CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WETER
Provider First Name:
SHERILYN
Provider Middle Name:
R
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CRNA
Provider Gender Code:
F

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:
1639164742
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/21/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1308
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BRANSON
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
65615
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
417-239-3392
Provider Business Mailing Address Fax Number:
417-239-3394

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
251 SKAGGS RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRANSON
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65616-2031
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
800-277-8151
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/14/2005

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:  029375 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 200100550A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 158887001 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 912798725 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 739499 . This is a "HEALTHLINK" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: P00202167 . This is a "RAILROAD" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 18866 . This is a "COX HEALTH" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 194111 . This is a "BCBS" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 20174319965616B004 . This is a "TRICARE" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".




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