Healthcare Provider Details

I. General information

NPI: 1679799803
Provider Name (Legal Business Name): WALTER EDWARD GELDRICH CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/17/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1545 FAWN DR
SEYMOUR TN
37865
US

IV. Provider business mailing address

1545 FAWN DR
SEYMOUR TN
37865
US

V. Phone/Fax

Practice location:
  • Phone: 865-579-6302
  • Fax:
Mailing address:
  • Phone: 865-579-6302
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number61293
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: