Provider Demographics
NPI:1629031992
Name:WALLACE, RICHARD ANTHONY (CRNA)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:ANTHONY
Last Name:WALLACE
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 1:969 OAK RIDGE TPKE # 316
Mailing Address - Street 2:
Mailing Address - City:OAK RIDGE
Mailing Address - State:TN
Mailing Address - Zip Code:37830-8832
Mailing Address - Country:US
Mailing Address - Phone:865-256-7711
Mailing Address - Fax:866-548-0571
Practice Address - Street 1:8045 ROANE MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:HARRIMAN
Practice Address - State:TN
Practice Address - Zip Code:37748-8333
Practice Address - Country:US
Practice Address - Phone:865-316-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-08
Last Update Date:2013-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN9332367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0454102553OtherTRICARE SOUTH HUMANA MILITARY
TN4317478OtherBCBS - COVER TENNESSEE
TN4317478OtherBCBS - MEDICARE ADVANTAGE (BLUEADVANTAGE)
TN616644300OtherDEPT OF LABOR WORKER'S COMP - DEEOIC PROGRAM
TN171975592453OtherHUMANA
TN4317478OtherBCBS - BLUE SELECT
TN3037582OtherCIGNA
TN4317478OtherBCBS - TENNCARE SELECT
TN4317478OtherBCBS - BLUE PREFERRED
TN1527480OtherTENNCARE, EFFECTIVE 4/5/12
TN1527480Medicaid
TN4317478OtherBCBS - BLUECARE
TN454102553OtherHUMANA GOLD
TN616644300OtherDEPT OF LABOR WOKER'S COMP - FECA PROGRAM
TN171975592453OtherHUMANA