Provider Demographics
NPI:1396775938
Name:CHISHOLM, WILLIAM G JR (CRNA)
Entity type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:G
Last Name:CHISHOLM
Suffix:JR
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 1:91 E TAMARACK LN
Mailing Address - Street 2:
Mailing Address - City:SHELTON
Mailing Address - State:WA
Mailing Address - Zip Code:98584-9402
Mailing Address - Country:US
Mailing Address - Phone:360-427-5747
Mailing Address - Fax:
Practice Address - Street 1:174 1ST AVE N
Practice Address - Street 2:
Practice Address - City:ILWACO
Practice Address - State:WA
Practice Address - Zip Code:98624-9137
Practice Address - Country:US
Practice Address - Phone:360-642-3181
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-03
Last Update Date:2016-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30001327367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9603887Medicaid
WA430073112OtherMEDICARE RAILROAD
OR210785Medicaid
WA430073112OtherMEDICARE RAILROAD
WAR54400Medicare UPIN