Healthcare Provider Details

I. General information

NPI: 1295989929
Provider Name (Legal Business Name): KEITH WANDOLOWSKI CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/07/2008
Last Update Date: 01/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10000 W COLONIAL DR
OCOEE FL
34761
US

IV. Provider business mailing address

14161 BARONESS CT
ORLANDO FL
32828-7801
US

V. Phone/Fax

Practice location:
  • Phone: 206-850-9151
  • Fax:
Mailing address:
  • Phone: 206-850-9151
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number268405
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: