Provider Demographics
NPI:1790881761
Name:WISCOMBE, GARY A (CRNA)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:A
Last Name:WISCOMBE
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 1:1727 RED BARN RD
Mailing Address - Street 2:
Mailing Address - City:SPRINGVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84663-3231
Mailing Address - Country:US
Mailing Address - Phone:801-491-9337
Mailing Address - Fax:
Practice Address - Street 1:10011 CENTENNIAL PKWY
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84070-4156
Practice Address - Country:US
Practice Address - Phone:801-993-9527
Practice Address - Fax:801-733-5872
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT0225185-4406367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT02251854400001OtherBCBS
UT22332OtherHEALTHY U
UT72748OtherPEHP
UTQM0000076551OtherALTIUS
UT851248OtherDESERET MUTUAL
UT107028132101OtherIHC
UTQMP0000033333378OtherMOLINA
UT851248OtherDESERET MUTUAL