Provider Demographics
NPI:1932291457
Name:LANDESS, WILLIAM WAYNE (CRNA)
Entity Type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:WAYNE
Last Name:LANDESS
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 1:16913 ERINS WAY
Mailing Address - Street 2:
Mailing Address - City:GRAND LEDGE
Mailing Address - State:MI
Mailing Address - Zip Code:48837-9767
Mailing Address - Country:US
Mailing Address - Phone:517-627-7675
Mailing Address - Fax:517-622-3537
Practice Address - Street 1:16913 ERINS WAY
Practice Address - Street 2:
Practice Address - City:GRAND LEDGE
Practice Address - State:MI
Practice Address - Zip Code:48837-9767
Practice Address - Country:US
Practice Address - Phone:517-627-7675
Practice Address - Fax:517-622-3537
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704156475367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIWL156475OtherBLUE CROSS BLUE SHIELD
MI20000130OtherPHYSICIAN'S HEALTH PLAN
MI2070130OtherPHP FAMILY CARE
MIWL156475OtherBLUE CROSS BLUE SHIELD