Healthcare Provider Details

I. General information

NPI: 1528166717
Provider Name (Legal Business Name): WALLACE SCOTT PHILLIPS CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 06/16/2022
Certification Date: 06/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1031 SCOTT TER
ATHENS GA
30606-6271
US

IV. Provider business mailing address

1031 SCOTT TER
ATHENS GA
30606-6271
US

V. Phone/Fax

Practice location:
  • Phone: 706-549-2700
  • Fax: 706-549-6592
Mailing address:
  • Phone: 706-424-1633
  • Fax: 706-549-2700

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN097986
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: