Provider Demographics
NPI:1639152952
Name:LAESCH, WALTER (CRNA)
Entity Type:Individual
Prefix:MR
First Name:WALTER
Middle Name:
Last Name:LAESCH
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 1:1016 W UNION ST
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61821-3322
Mailing Address - Country:US
Mailing Address - Phone:217-359-2752
Mailing Address - Fax:217-359-8923
Practice Address - Street 1:40 10 RIVERKNOLL DR
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61822
Practice Address - Country:US
Practice Address - Phone:217-356-5963
Practice Address - Fax:217-352-8947
Is Sole Proprietor?:No
Enumeration Date:2005-11-21
Last Update Date:2011-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209-000371367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL09223524OtherBC/BS GROUP ID NO.
IL371390028001OtherTRICARE GROUP ID NO.
IL216564000OtherWORKMAN'S COMP GROUP ID
ILCG3273OtherRR MEDICARE GROUP ID NO.
IL430052840OtherRR MEDICARE GROUP ID NO.
ILCG3273OtherRR MEDICARE GROUP ID NO.
IL430052840OtherRR MEDICARE GROUP ID NO.