Healthcare Provider Details

I. General information

NPI: 1831541408
Provider Name (Legal Business Name): STEPHEN WATT CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2016
Last Update Date: 07/01/2026
Certification Date: 07/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4076 NEELY ROAD
FORT WAINWRIGHT AK
99703
US

IV. Provider business mailing address

3510 MOONSHINE RUN
FAIRBANKS AK
99709-5786
US

V. Phone/Fax

Practice location:
  • Phone: 907-361-6021
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number105152
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: