Provider Demographics
NPI:1144205469
Name:TOBIAS, WANDA T (CRNA)
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:T
Last Name:TOBIAS
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:WANDA
Other - Middle Name:L
Other - Last Name:TAYLOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:10628 PARK RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28210-8407
Mailing Address - Country:US
Mailing Address - Phone:301-741-6992
Mailing Address - Fax:
Practice Address - Street 1:10628 PARK RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28210-8407
Practice Address - Country:US
Practice Address - Phone:301-741-6992
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-09
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024177506367500000X
SC17827367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD016508S50Medicare PIN