Basic Information
| Provider Information | |||||||||
| NPI: | 1245294735 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WEGELT-WUNDROW | ||||||||
| FirstName: | DIANE | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CRNA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WEGELT | ||||||||
| OtherFirstName: | DIANE | ||||||||
| OtherMiddleName: | LYNN | ||||||||
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| OtherCredential: | CRNA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 4346 | ||||||||
| Address2: | DEPT 398 | ||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 772104346 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2813588114 | ||||||||
| FaxNumber: | 2813580609 | ||||||||
| Practice Location | |||||||||
| Address1: | 333 N TEXAS AVE | ||||||||
| Address2: | |||||||||
| City: | WEBSTER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 775984966 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2813351700 | ||||||||
| FaxNumber: | 2813351708 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 512064 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 10069098 | 01 | TX | AMERIGROUP | OTHER | P0036114 | 01 | TX | RAILROAD MEDICARE | OTHER | 86155U | 01 | TX | BLUE CROSS/BLUE SHIELD | OTHER | 033610 | 01 | TX | AANA RECERTIFICATION | OTHER |