Provider Demographics
NPI:1255481875
Name:WOLBERS, RUSSELL MATTHEW (CRNA)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:MATTHEW
Last Name:WOLBERS
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 1:8684 ROYAL MELBOURNE CIR
Mailing Address - Street 2:
Mailing Address - City:PEYTON
Mailing Address - State:CO
Mailing Address - Zip Code:80831-4045
Mailing Address - Country:US
Mailing Address - Phone:702-983-4747
Mailing Address - Fax:
Practice Address - Street 1:4102 PINION DR
Practice Address - Street 2:
Practice Address - City:USAF ACADEMY
Practice Address - State:CO
Practice Address - Zip Code:80840-2502
Practice Address - Country:US
Practice Address - Phone:719-333-5651
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN322992367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered