Provider Demographics
NPI:1952399545
Name:WOLFE, DARRELL LEROY JR (CRNA)
Entity Type:Individual
Prefix:
First Name:DARRELL
Middle Name:LEROY
Last Name:WOLFE
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:PO BOX 711841
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43271-0001
Mailing Address - Country:US
Mailing Address - Phone:304-346-9400
Mailing Address - Fax:
Practice Address - Street 1:1400 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:HURRICANE
Practice Address - State:WV
Practice Address - Zip Code:25526-9202
Practice Address - Country:US
Practice Address - Phone:304-346-9400
Practice Address - Fax:304-345-7320
Is Sole Proprietor?:No
Enumeration Date:2005-10-09
Last Update Date:2021-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1103273163W00000X
TNAPN0000010406367500000X
OH07240367500000X
KY054720367500000X
WV006930367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200253980Medicaid
WV1073324OtherBRICKSTREET
KY7400958000Medicaid
000000540386OtherANTHEM
OH2376263Medicaid
IN200253980Medicaid
000000540386OtherANTHEM
0918140Medicare PIN