Provider Demographics
NPI:1376672006
Name:WHEELER, JERRY C (CRNA)
Entity Type:Individual
Prefix:MR
First Name:JERRY
Middle Name:C
Last Name:WHEELER
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:APACHE TRAIL
Mailing Address - Street 2:NF 6 LAKE CHEROKEE
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75603
Mailing Address - Country:US
Mailing Address - Phone:903-720-2334
Mailing Address - Fax:
Practice Address - Street 1:300 WILSON ST
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:TX
Practice Address - Zip Code:75652-5956
Practice Address - Country:US
Practice Address - Phone:903-655-3830
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-06
Last Update Date:2008-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX232196367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX85323HMedicare PIN