Provider Demographics
NPI:1134151186
Name:WISENOR, RANDALL E (CRNA)
Entity type:Individual
Prefix:
First Name:RANDALL
Middle Name:E
Last Name:WISENOR
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 1:203 BAYSIDE DR
Mailing Address - Street 2:
Mailing Address - City:WEST MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71291-8696
Mailing Address - Country:US
Mailing Address - Phone:318-396-1379
Mailing Address - Fax:
Practice Address - Street 1:203 BAYSIDE DR
Practice Address - Street 2:
Practice Address - City:WEST MONROE
Practice Address - State:LA
Practice Address - Zip Code:71291-8696
Practice Address - Country:US
Practice Address - Phone:318-396-1379
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2008-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN070478163W00000X
LAAPO2815367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1673749Medicaid
LA1673749Medicaid
LA5T906Medicare PIN