Provider Demographics
NPI:1497792659
Name:WOODSON, CHARLES VINCENT (CRNA)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:VINCENT
Last Name:WOODSON
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:PO BOX 5635
Mailing Address - Street 2:ATTN: MARIA MITCHELL
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47407
Mailing Address - Country:US
Mailing Address - Phone:812-337-5003
Mailing Address - Fax:812-337-5010
Practice Address - Street 1:2920 MCINTIRE DRIVE, SUITE 150
Practice Address - Street 2:ATTN: MARIA MITCHELL
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403
Practice Address - Country:US
Practice Address - Phone:812-337-5003
Practice Address - Fax:812-337-5010
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-31
Last Update Date:2007-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28126400A367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000386593OtherSIA-ANTHEM