Healthcare Provider Details

I. General information

NPI: 1629031992
Provider Name (Legal Business Name): RICHARD ANTHONY WALLACE CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/08/2006
Last Update Date: 09/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8045 ROANE MEDICAL CENTER DR
HARRIMAN TN
37748-8333
US

IV. Provider business mailing address

969 OAK RIDGE TPKE # 316
OAK RIDGE TN
37830-8832
US

V. Phone/Fax

Practice location:
  • Phone: 865-316-1000
  • Fax:
Mailing address:
  • Phone: 865-256-7711
  • Fax: 866-548-0571

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number9332
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: