Healthcare Provider Details

I. General information

NPI: 1619100997
Provider Name (Legal Business Name): COREY BRIAN WARDELL CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/02/2009
Last Update Date: 10/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1959 NE PACIFIC ST
SEATTLE WA
98195
US

IV. Provider business mailing address

PO BOX 50095
SEATTLE WA
98145-5095
US

V. Phone/Fax

Practice location:
  • Phone: 206-598-4260
  • Fax:
Mailing address:
  • Phone: 206-520-5700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAP60451800
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: