Provider Demographics
NPI:1649738394
Name:CORNERSTONE ANESTHESIA LLC
Entity Type:Organization
Organization Name:CORNERSTONE ANESTHESIA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CRNA
Authorized Official - Prefix:
Authorized Official - First Name:TISHA
Authorized Official - Middle Name:
Authorized Official - Last Name:WIKUM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:316-619-6652
Mailing Address - Street 1:39 NW 48 RD
Mailing Address - Street 2:
Mailing Address - City:GREAT BEND
Mailing Address - State:KS
Mailing Address - Zip Code:67530-9084
Mailing Address - Country:US
Mailing Address - Phone:316-619-6652
Mailing Address - Fax:
Practice Address - Street 1:250 W 9TH ST
Practice Address - Street 2:
Practice Address - City:HOISINGTON
Practice Address - State:KS
Practice Address - Zip Code:67544-1706
Practice Address - Country:US
Practice Address - Phone:316-619-6652
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-12
Last Update Date:2019-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty