Healthcare Provider Details

I. General information

NPI: 1497359012
Provider Name (Legal Business Name): JUSTIN WANINGER CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/24/2020
Last Update Date: 01/22/2021
Certification Date: 01/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3700 S MAIN ST
BLACKSBURG VA
24060-7017
US

IV. Provider business mailing address

1838 CARLETON DR
SALEM VA
24153
US

V. Phone/Fax

Practice location:
  • Phone: 540-951-1111
  • Fax:
Mailing address:
  • Phone: 812-630-0100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number0001275299
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number0024180835
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: