Provider Demographics
NPI:1144737982
Name:WISECAVER, CARL EDMOND (CRNA)
Entity Type:Individual
Prefix:
First Name:CARL
Middle Name:EDMOND
Last Name:WISECAVER
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7406 LONG SHOT LN
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37918-1024
Mailing Address - Country:US
Mailing Address - Phone:865-315-0090
Mailing Address - Fax:
Practice Address - Street 1:230 W MAIN ST STE 200
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:KY
Practice Address - Zip Code:40422-1873
Practice Address - Country:US
Practice Address - Phone:859-236-3726
Practice Address - Fax:859-236-3019
Is Sole Proprietor?:No
Enumeration Date:2018-01-02
Last Update Date:2018-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3011958367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered