Provider Demographics
NPI:1154352045
Name:WIENTJES, RANDY RAY (CRNA)
Entity type:Individual
Prefix:MR
First Name:RANDY
Middle Name:RAY
Last Name:WIENTJES
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 1:3042 LAKEVIEW DR
Mailing Address - Street 2:
Mailing Address - City:METROPOLIS
Mailing Address - State:IL
Mailing Address - Zip Code:62960-3119
Mailing Address - Country:US
Mailing Address - Phone:618-524-9217
Mailing Address - Fax:618-524-2158
Practice Address - Street 1:3042 LAKEVIEW DR
Practice Address - Street 2:
Practice Address - City:METROPOLIS
Practice Address - State:IL
Practice Address - Zip Code:62960-3119
Practice Address - Country:US
Practice Address - Phone:618-524-9217
Practice Address - Fax:618-524-2158
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-06
Last Update Date:2015-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209-004142367500000X
SDCR000381367500000X
KY3001002367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY74007063Medicaid
KYP01099568OtherRAIL ROAD MEDICARE
IL967170Medicare PIN
KY00937007Medicare PIN
KYP01099568OtherRAIL ROAD MEDICARE
KY74007063Medicaid