Healthcare Provider Details

I. General information

NPI: 1194783357
Provider Name (Legal Business Name): TIMOTHY J WAND CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2006
Last Update Date: 05/04/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3801 S NATIONAL
SPRINGFIELD MO
65807
US

IV. Provider business mailing address

1000 E PRIMROSE STE 520
SPRINGFIELD MO
65807
US

V. Phone/Fax

Practice location:
  • Phone: 417-269-6000
  • Fax:
Mailing address:
  • Phone: 417-269-4550
  • Fax: 417-269-4558

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number123480
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number123480
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: