Healthcare Provider Details

I. General information

NPI: 1841225851
Provider Name (Legal Business Name): LARRY J WOODGATE CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 W AVENUE J
LANCASTER CA
93534-2814
US

IV. Provider business mailing address

101 S 1ST ST SUITE 1000
BURBANK CA
91502-1928
US

V. Phone/Fax

Practice location:
  • Phone: 661-949-5000
  • Fax: 661-951-4327
Mailing address:
  • Phone: 818-845-6206
  • Fax: 818-845-9774

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number1056313230
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: