Provider Demographics
NPI:1184177065
Name:WILCOX, RUSSELL TOLMAN (CRNA)
Entity type:Individual
Prefix:
First Name:RUSSELL
Middle Name:TOLMAN
Last Name:WILCOX
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 1:4029 QUARTER DOME CIR
Mailing Address - Street 2:
Mailing Address - City:RANCHO CORDOVA
Mailing Address - State:CA
Mailing Address - Zip Code:95742-7720
Mailing Address - Country:US
Mailing Address - Phone:801-592-7415
Mailing Address - Fax:
Practice Address - Street 1:4029 QUARTER DOME CIR
Practice Address - Street 2:
Practice Address - City:RANCHO CORDOVA
Practice Address - State:CA
Practice Address - Zip Code:95742-7720
Practice Address - Country:US
Practice Address - Phone:801-592-7415
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-27
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95000452367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered