Provider Demographics
NPI:1154321743
Name:WALTHALL, JOHN C (CRNA)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:C
Last Name:WALTHALL
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 1:148 WELCHMAN AVE
Mailing Address - Street 2:
Mailing Address - City:GOOSE CREEK
Mailing Address - State:SC
Mailing Address - Zip Code:29445-7152
Mailing Address - Country:US
Mailing Address - Phone:843-327-6616
Mailing Address - Fax:
Practice Address - Street 1:1735 TAYLOR ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29201-3452
Practice Address - Country:US
Practice Address - Phone:803-254-8449
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-26
Last Update Date:2010-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC67298367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCQ32623Medicare UPIN