Provider Demographics
NPI:1699759696
Name:WOLFE, RICHARD RAYMOND (CRNA)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:RAYMOND
Last Name:WOLFE
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:PO BOX 2585
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31902-2585
Mailing Address - Country:US
Mailing Address - Phone:706-660-8505
Mailing Address - Fax:706-660-9390
Practice Address - Street 1:298 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:SENECA
Practice Address - State:SC
Practice Address - Zip Code:29672-9443
Practice Address - Country:US
Practice Address - Phone:864-882-3351
Practice Address - Fax:706-660-9390
Is Sole Proprietor?:No
Enumeration Date:2005-12-02
Last Update Date:2012-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCR43447367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP2991Medicaid
SCGP2991Medicaid