Healthcare Provider Details

I. General information

NPI: 1790881761
Provider Name (Legal Business Name): GARY A WISCOMBE CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10011 CENTENNIAL PKWY
SANDY UT
84070-4156
US

IV. Provider business mailing address

1727 RED BARN RD
SPRINGVILLE UT
84663-3231
US

V. Phone/Fax

Practice location:
  • Phone: 801-993-9527
  • Fax: 801-733-5872
Mailing address:
  • Phone: 801-491-9337
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number0225185-4406
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: