Provider Demographics
NPI:1295711430
Name:WHEEKER, LARRY C (RN, CRNA)
Entity type:Individual
Prefix:MR
First Name:LARRY
Middle Name:C
Last Name:WHEEKER
Suffix:
Gender:M
Credentials:RN, CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 WOODLAND DR
Mailing Address - Street 2:
Mailing Address - City:COOS BAY
Mailing Address - State:OR
Mailing Address - Zip Code:97420-0000
Mailing Address - Country:US
Mailing Address - Phone:541-267-5151
Mailing Address - Fax:541-266-4501
Practice Address - Street 1:1900 WOODLAND DR
Practice Address - Street 2:
Practice Address - City:COOS BAY
Practice Address - State:OR
Practice Address - Zip Code:97420-0000
Practice Address - Country:US
Practice Address - Phone:541-267-5151
Practice Address - Fax:541-266-4501
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-20
Last Update Date:2010-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200160039CRNA367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR268921Medicaid
ORR0000WFBTVOtherMEDICARE GROUP PIN NUMBER
OR079044214RNOtherRN LICENSE #
OR1407812365OtherNBMC GROUP NPI NUMBER
OR430069427OtherRR MEDICARE PTAN NUMBER
ORCD8723OtherRR MEDICARE GROUP NUMBER
OR031589OtherCRNA RECERTIFICATION #
ORR0000WFBTVOtherMEDICARE GROUP PIN NUMBER
OR268921Medicaid
ORR0000WFBTVOtherMEDICARE GROUP PIN NUMBER
OR0577260001Medicare NSC
OR930635514OtherGROUP TAX ID NUMBER