Healthcare Provider Details

I. General information

NPI: 1417633322
Provider Name (Legal Business Name): ALEC WISCOMBE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2023
Last Update Date: 06/26/2023
Certification Date: 06/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6965 CUMBERLAND GAP PARKWAY
HARROGATE TN
37752
US

IV. Provider business mailing address

412 W FOUNDERS BLVD
SARATOGA SPGS UT
84045
US

V. Phone/Fax

Practice location:
  • Phone: 423-869-3611
  • Fax:
Mailing address:
  • Phone: 423-307-2037
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number11078999-3102
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: