Provider Demographics
NPI:1326024050
Name:WOLFF, MICHAEL PHILLIP (CRNA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:PHILLIP
Last Name:WOLFF
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 1:1042 N MOUNTAIN AVE
Mailing Address - Street 2:BOX 351
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-3695
Mailing Address - Country:US
Mailing Address - Phone:909-908-9137
Mailing Address - Fax:
Practice Address - Street 1:1042 N MOUNTAIN AVE
Practice Address - Street 2:BOX 351
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-3695
Practice Address - Country:US
Practice Address - Phone:909-908-9137
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-15
Last Update Date:2010-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARN452631367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARN4526310Medicaid
430079036OtherRAILROAD MEDICARE
ZZZ24817ZMedicare ID - Type Unspecified
CARN4526310Medicaid