Healthcare Provider Details

I. General information

NPI: 1104330687
Provider Name (Legal Business Name): WILLIE BERT MCCORVEY JR. CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/20/2017
Last Update Date: 09/14/2025
Certification Date: 09/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2450 S TELSHOR BLVD
LAS CRUCES NM
88011-5069
US

IV. Provider business mailing address

5850 N MESA ST STE A182
EL PASO TX
79912-4681
US

V. Phone/Fax

Practice location:
  • Phone: 525-522-8641
  • Fax:
Mailing address:
  • Phone: 228-238-0260
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number78782
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: