Provider Demographics
NPI:1407854755
Name:WOODRUFF, WALTER W (CRNA)
Entity Type:Individual
Prefix:
First Name:WALTER
Middle Name:W
Last Name:WOODRUFF
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 1:4100 SUMMERHILL RD
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75503-2732
Mailing Address - Country:US
Mailing Address - Phone:903-735-9802
Mailing Address - Fax:903-735-9806
Practice Address - Street 1:4100 SUMMERHILL RD
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503-2732
Practice Address - Country:US
Practice Address - Phone:903-735-9802
Practice Address - Fax:903-735-9806
Is Sole Proprietor?:No
Enumeration Date:2005-07-11
Last Update Date:2014-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX504083367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX002849001Medicaid
TX83136COtherBLUE CROSS
AR117305701Medicaid
AR84329OtherBLUE CROSS
TX002849001Medicaid
430011917Medicare ID - Type UnspecifiedRAILROAD