Healthcare Provider Details

I. General information

NPI: 1306939897
Provider Name (Legal Business Name): WESLEY WEBSTER CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1127 NORTH CHURCH STREET
GREENSBORO NC
27401
US

IV. Provider business mailing address

PO BOX 26595
GREENSBORO NC
27415-6595
US

V. Phone/Fax

Practice location:
  • Phone: 336-832-7100
  • Fax:
Mailing address:
  • Phone: 336-832-8014
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number079269
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: