Healthcare Provider Details

I. General information

NPI: 1306186192
Provider Name (Legal Business Name): BRYCE RIAL WHEELER CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/15/2013
Last Update Date: 01/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1055 N CURTIS RD
BOISE ID
83706-1309
US

IV. Provider business mailing address

1055 N CURTIS RD
BOISE ID
83706-1309
US

V. Phone/Fax

Practice location:
  • Phone: 208-367-6416
  • Fax: 208-367-2742
Mailing address:
  • Phone: 208-367-6416
  • Fax: 208-367-2742

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberCRNA0913
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: