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General NPI Number Information
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NPI Number | 1801625421
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Entity Type | Individual
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Provider Name | ELLIS LAMAR WYNN IV CRNA
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Gender | Male
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Dates
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Enumeration Date | 07/31/2024
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Last Update Date | 02/03/2026
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Provider Practice Location Address
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Address Line | 1139 PICKET FENCE DR
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City | EVANS
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State | GA
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Zip | 30809-9158
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Country | US
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Telephone | 229-854-9517
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Fax |
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Provider Business Mailing Address
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Address Line | 1636 S CASTLE STONE SQ
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City | BILLINGS
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State | MT
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Zip | 59106-9724
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Country | US
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Telephone | 229-854-9517
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 163W00000X
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Taxonomy Name | Registered Nurse
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License Number | RN286537
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License Number State | GA
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Taxonomy #2
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Taxonomy Code | 367500000X
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Taxonomy Name | Certified Registered Nurse Anesthetist
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License Number | 267591
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License Number State | MT
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