Healthcare Provider Details

I. General information

NPI: 1396775938
Provider Name (Legal Business Name): WILLIAM G CHISHOLM JR. CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/03/2006
Last Update Date: 02/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

174 1ST AVE N
ILWACO WA
98624-9137
US

IV. Provider business mailing address

91 E TAMARACK LN
SHELTON WA
98584-9402
US

V. Phone/Fax

Practice location:
  • Phone: 360-642-3181
  • Fax:
Mailing address:
  • Phone: 360-427-5747
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAP30001327
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: