Healthcare Provider Details

I. General information

NPI: 1467022889
Provider Name (Legal Business Name): WESLEY KYLE MAUGHON DNP, CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/28/2021
Last Update Date: 05/28/2024
Certification Date: 05/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 ELLIOT WAY
MANCHESTER NH
03103-3502
US

IV. Provider business mailing address

PO BOX 23321
NEW YORK NY
10087-3221
US

V. Phone/Fax

Practice location:
  • Phone: 110-111-0117
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number319065
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number139725
License Number StateNH
# 3
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number28769
License Number StateSC
# 4
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number088530-23
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: