Healthcare Provider Details

I. General information

NPI: 1639223464
Provider Name (Legal Business Name): JAMES DAVID WADE CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/22/2007
Last Update Date: 12/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35 ALBANY RD STE C
CARBONDALE IL
62903-7605
US

IV. Provider business mailing address

35 ALBANY RD STE C
CARBONDALE IL
62903-7605
US

V. Phone/Fax

Practice location:
  • Phone: 618-457-5111
  • Fax: 618-457-6560
Mailing address:
  • Phone: 618-457-5111
  • Fax: 618-457-6560

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number209006566
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: