Provider Demographics
NPI:1912960865
Name:WAYNE, PAUL (CRNA)
Entity Type:Individual
Prefix:MR
First Name:PAUL
Middle Name:
Last Name:WAYNE
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:MR
Other - First Name:PAUL
Other - Middle Name:
Other - Last Name:WAYNE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:77 CALLE PORTAL STE B260A
Mailing Address - Street 2:
Mailing Address - City:SIERRA VISTA
Mailing Address - State:AZ
Mailing Address - Zip Code:85635-2998
Mailing Address - Country:US
Mailing Address - Phone:520-226-4338
Mailing Address - Fax:
Practice Address - Street 1:75 COLONIA DE SALUD STE 200C
Practice Address - Street 2:
Practice Address - City:SIERRA VISTA
Practice Address - State:AZ
Practice Address - Zip Code:85635-2486
Practice Address - Country:US
Practice Address - Phone:520-226-4338
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-11
Last Update Date:2016-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP60037040367500000X
WARN60090792163W00000X
AZCRNA367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9662008Medicaid
AZ884282Medicaid
WAG8884304Medicare PIN
WA9662008Medicaid
AZ884282Medicaid