Provider Demographics
NPI:1932172434
Name:WATERLANDER, EDNA G (CRNA)
Entity Type:Individual
Prefix:
First Name:EDNA
Middle Name:G
Last Name:WATERLANDER
Suffix:
Gender:F
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:PO BOX 11219
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76110-0219
Mailing Address - Country:US
Mailing Address - Phone:817-294-7444
Mailing Address - Fax:817-294-7172
Practice Address - Street 1:140 RIVER NORTH BLVD
Practice Address - Street 2:
Practice Address - City:STEPHENVILLE
Practice Address - State:TX
Practice Address - Zip Code:76401-1803
Practice Address - Country:US
Practice Address - Phone:254-965-7020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-07
Last Update Date:2009-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX691962367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00C56UOtherBCBSTX
TX00C56UOtherBCBSTX
TX613651Medicare PIN
TXP00698878Medicare PIN