MEDICARE: MR. ROBERT EUGENE WISE CRNA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	367500000X	Certified Registered Nurse Anesthetist	5586107-4406	UT

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	P00469890	OTHER	NM	RR MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1558492637
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ROBERT EUGENE WISE CRNA

Provider Business Mailing Address
First Line	:	195 E FIDDLERS CANYON RD
Second Line	:	UNIT 14
City	:	CEDAR CITY
State	:	UT
Zip	:	84720-8744
Country	:	US
Telephone Number	:	435-559-3136
Fax Number	:

Provider Business Practice Location Address
First Line	:	195 E FIDDLERS CANYON RD
Second Line	:	UNIT 14
City	:	CEDAR CITY
State	:	UT
Zip	:	84720-8744
Country	:	US
Telephone Number	:	435-559-3136
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/08/2007
Last Update Date	:	07/30/2008

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