Provider Demographics
NPI:1639289929
Name:WOLCOTT, WESLEY M (CRNA)
Entity Type:Individual
Prefix:
First Name:WESLEY
Middle Name:M
Last Name:WOLCOTT
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 1:835 SE BISHOP BLVD
Mailing Address - Street 2:
Mailing Address - City:PULLMAN
Mailing Address - State:WA
Mailing Address - Zip Code:99163-5512
Mailing Address - Country:US
Mailing Address - Phone:509-332-2541
Mailing Address - Fax:
Practice Address - Street 1:835 SE BISHOP BLVD
Practice Address - Street 2:
Practice Address - City:PULLMAN
Practice Address - State:WA
Practice Address - Zip Code:99163-5512
Practice Address - Country:US
Practice Address - Phone:509-332-2541
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30005662367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9630989Medicaid
WA911603497OtherTAX ID
WA8803180Medicare ID - Type Unspecified