Provider Demographics
NPI:1134750334
Name:BALZER, PHILLIP WILLIAM (CRNA)
Entity type:Individual
Prefix:
First Name:PHILLIP
Middle Name:WILLIAM
Last Name:BALZER
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 1:5205 TIMBERCREEK DR
Mailing Address - Street 2:
Mailing Address - City:NORTH CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23237-3169
Mailing Address - Country:US
Mailing Address - Phone:864-907-3265
Mailing Address - Fax:
Practice Address - Street 1:1200 E BROAD ST
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23298-5058
Practice Address - Country:US
Practice Address - Phone:804-828-9000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-28
Last Update Date:2020-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001250924163W00000X
VA0024178743367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0024178743OtherNURSE PRACTITIONER LICENSE
VA0001250924OtherRN LICENCE