Provider Demographics
NPI:1780798389
Name:STUBBS, WAYNE LEWIS (CRNA)
Entity type:Individual
Prefix:
First Name:WAYNE
Middle Name:LEWIS
Last Name:STUBBS
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 1:2282 W HOLLY CIR
Mailing Address - Street 2:
Mailing Address - City:CEDAR CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84720-1836
Mailing Address - Country:US
Mailing Address - Phone:435-865-7444
Mailing Address - Fax:
Practice Address - Street 1:1303 N MAIN ST
Practice Address - Street 2:
Practice Address - City:CEDAR CITY
Practice Address - State:UT
Practice Address - Zip Code:84720-9746
Practice Address - Country:US
Practice Address - Phone:801-993-9501
Practice Address - Fax:801-733-5872
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT204574-4406367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT56720OtherHEALTHY U
UTPR04686OtherMOLINA
UT107006673103OtherIHC
UT870551530ST1OtherEDUCATORS MUTUAL
UT262975OtherDESERET MUTUAL
UT2090117OtherUNITED HEALTHCARE
AZ796237Medicaid
UT80055OtherPEHP
UTP00147018Medicare ID - Type UnspecifiedRAILROAD MEDICARE