Healthcare Provider Details

I. General information

NPI: 1972818110
Provider Name (Legal Business Name): JOHN A. WANNER CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2010
Last Update Date: 08/12/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

271 CAREW ST
SPRINGFIELD MA
01104-2377
US

IV. Provider business mailing address

1613 HARRISON PKWY STE 200
SUNRISE FL
33323-2853
US

V. Phone/Fax

Practice location:
  • Phone: 413-748-9000
  • Fax:
Mailing address:
  • Phone: 800-437-2672
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN2267170
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: