Provider Demographics
NPI:1558492637
Name:WISE, ROBERT EUGENE (CRNA)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:EUGENE
Last Name:WISE
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 1:195 E FIDDLERS CANYON RD
Mailing Address - Street 2:UNIT 14
Mailing Address - City:CEDAR CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84720-8744
Mailing Address - Country:US
Mailing Address - Phone:435-559-3136
Mailing Address - Fax:
Practice Address - Street 1:195 E FIDDLERS CANYON RD
Practice Address - Street 2:UNIT 14
Practice Address - City:CEDAR CITY
Practice Address - State:UT
Practice Address - Zip Code:84720-8744
Practice Address - Country:US
Practice Address - Phone:435-559-3136
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-08
Last Update Date:2008-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5586107-4406367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM86924214Medicaid
NMP00469890OtherRR MEDICARE
NM346723402Medicare PIN