Provider Demographics
NPI:1619198363
Name:WOOTEN, WILLIAM KEITH (CRNA)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:KEITH
Last Name:WOOTEN
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 1:510 E CLINTON AVE
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:TX
Mailing Address - Zip Code:75751-3410
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:510 E CLINTON AVE
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:TX
Practice Address - Zip Code:75751-3410
Practice Address - Country:US
Practice Address - Phone:903-677-7434
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2017-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN054618163W00000X
LAAP02498367500000X
TXAP129728367500000X
TX888140163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1439649Medicaid
TX3544850-02Medicaid
TX3544850-02Medicaid
TX463666YNM4Medicare PIN
LA4B766Medicare PIN