Provider Demographics
NPI:1275687816
Name:WIGHT, PHYLLIS A (CRNA)
Entity Type:Individual
Prefix:MRS
First Name:PHYLLIS
Middle Name:A
Last Name:WIGHT
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:PHYLLIS
Other - Middle Name:ANN
Other - Last Name:WIGHT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CRNA
Mailing Address - Street 1:PO BOX 551420
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33355-1420
Mailing Address - Country:US
Mailing Address - Phone:800-243-3839
Mailing Address - Fax:954-839-2569
Practice Address - Street 1:1000 MEDICAL CENTER BLVD
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-0000
Practice Address - Country:US
Practice Address - Phone:770-277-3056
Practice Address - Fax:855-204-5244
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-22
Last Update Date:2014-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN045468 CRNA367500000X
GARN045468367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA828358910AMedicaid
GA202I438753Medicare PIN