Provider Demographics
NPI:1770582736
Name:HALL, DWIGHT M (CRNA)
Entity type:Individual
Prefix:MR
First Name:DWIGHT
Middle Name:M
Last Name:HALL
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 1:1110 TURNER DR
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75601-6750
Mailing Address - Country:US
Mailing Address - Phone:903-720-1459
Mailing Address - Fax:903-720-1459
Practice Address - Street 1:300 WILSON ST
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:TX
Practice Address - Zip Code:75652-5956
Practice Address - Country:US
Practice Address - Phone:903-657-7541
Practice Address - Fax:903-596-7541
Is Sole Proprietor?:No
Enumeration Date:2005-07-20
Last Update Date:2014-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX47045367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX85006UOtherBLUE CROSS BLUE SHIELD
TX088614504Medicaid
TX83695CMedicare PIN
TX85006UOtherBLUE CROSS BLUE SHIELD