Healthcare Provider Details

I. General information

NPI: 1013974369
Provider Name (Legal Business Name): RONNIE JAY WING CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2006
Last Update Date: 06/20/2022
Certification Date: 06/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1775 BROWNING WAY STE 102
ELKO NV
89801-8338
US

IV. Provider business mailing address

660 S COOLIDGE ST
MOSES LAKE WA
98837-1872
US

V. Phone/Fax

Practice location:
  • Phone: 775-299-4555
  • Fax: 775-525-5257
Mailing address:
  • Phone: 509-793-9715
  • Fax: 509-764-3244

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number824627
License Number StateNV
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAP61066966
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberCRNA000228
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: