Provider Demographics
NPI:1689784969
Name:WINTERBOTTOM, EDWARD R (CRNA)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:R
Last Name:WINTERBOTTOM
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:PO BOX 487
Mailing Address - Street 2:
Mailing Address - City:PULLMAN
Mailing Address - State:WA
Mailing Address - Zip Code:99163-0487
Mailing Address - Country:US
Mailing Address - Phone:509-332-4051
Mailing Address - Fax:509-332-4051
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:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30005207367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9609629Medicaid
WA911603497OtherTAX ID
WAAB37700Medicare ID - Type Unspecified