Provider Demographics
NPI:1992044309
Name:ELLENDER, MICHEAL WAYNE (CRNA)
Entity Type:Individual
Prefix:
First Name:MICHEAL
Middle Name:WAYNE
Last Name:ELLENDER
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 1:4150 NELSON RD STE A4
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70605-4169
Mailing Address - Country:US
Mailing Address - Phone:337-540-6900
Mailing Address - Fax:
Practice Address - Street 1:4150 NELSON RD STE A4
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70605-4169
Practice Address - Country:US
Practice Address - Phone:337-540-6900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-05
Last Update Date:2013-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP07167367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered