1962738781 NPI number — EMILY D WUERDEMAN CRNA

Table of content: EMILY D WUERDEMAN CRNA (NPI 1962738781)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962738781 NPI number — EMILY D WUERDEMAN CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WUERDEMAN
Provider First Name:
EMILY
Provider Middle Name:
D
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:
1962738781
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/05/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1006 N ANDERSON ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TACOMA
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98406-6814
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
731-796-0407
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3209S 23RD ST 340
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TACOMA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98405-1602
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-503-2598
Provider Business Practice Location Address Fax Number:
253-404-0506
Provider Enumeration Date:
10/29/2009

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:  150796 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 367500000X , with the licence number: AP60577045 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: G8944647 . This is a "MDCR PTAN (K)" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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