Healthcare Provider Details

I. General information

NPI: 1083785281
Provider Name (Legal Business Name): RICHARD CARVER CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/11/2006
Last Update Date: 08/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

195 OVERTHRUST RD.
EVANSTON WY
82930-9266
US

IV. Provider business mailing address

PO BOX 1477
EVANSTON WY
82931-1477
US

V. Phone/Fax

Practice location:
  • Phone: 307-444-3600
  • Fax: 307-789-3760
Mailing address:
  • Phone: 307-789-1219
  • Fax: 307-789-3760

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number21113.785
License Number StateWY
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number264797-4406
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: