Provider Demographics
NPI:1528011996
Name:BLUMHARDT, WAYDE RUSSELL (CRNA)
Entity Type:Individual
Prefix:
First Name:WAYDE
Middle Name:RUSSELL
Last Name:BLUMHARDT
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 2758
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:IA
Mailing Address - Zip Code:50704-2758
Mailing Address - Country:US
Mailing Address - Phone:319-235-5390
Mailing Address - Fax:319-233-1630
Practice Address - Street 1:1825 LOGAN AVE
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:IA
Practice Address - Zip Code:50703
Practice Address - Country:US
Practice Address - Phone:319-235-3886
Practice Address - Fax:319-233-1630
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2007-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAD-074832367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA2062018Medicaid
IA55001OtherWELLMARK INS PLAN
IA42141730780OtherJOHN DEERE HEALTH INS
IA3062018Medicaid
IA2062018Medicaid