Provider Demographics
NPI:1376857078
Name:WENSLOW, MICHAEL R (CRNA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:R
Last Name:WENSLOW
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 1:2855 OLD HIGHWAY 5
Mailing Address - Street 2:
Mailing Address - City:BLUE RIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30513-6248
Mailing Address - Country:US
Mailing Address - Phone:706-632-3711
Mailing Address - Fax:706-946-4430
Practice Address - Street 1:417 W 3RD AVE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31701-1943
Practice Address - Country:US
Practice Address - Phone:229-312-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-05
Last Update Date:2015-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN181342367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered