Provider Demographics
NPI:1891789111
Name:WALL, CURTISS A (CRNA)
Entity Type:Individual
Prefix:
First Name:CURTISS
Middle Name:A
Last Name:WALL
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 20537
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34204-0537
Mailing Address - Country:US
Mailing Address - Phone:941-747-2830
Mailing Address - Fax:941-747-6170
Practice Address - Street 1:227 MCCALLISTER
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47802
Practice Address - Country:US
Practice Address - Phone:765-832-7372
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-31
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28114266A367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL$$$$$$$$$001Medicaid
INCC9250Medicare PIN
IL$$$$$$$$$001Medicaid