Basic Information
| Provider Information | |||||||||
| NPI: | 1528011996 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLUMHARDT | ||||||||
| FirstName: | WAYDE | ||||||||
| MiddleName: | RUSSELL | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2758 | ||||||||
| Address2: | |||||||||
| City: | WATERLOO | ||||||||
| State: | IA | ||||||||
| PostalCode: | 507042758 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3192355390 | ||||||||
| FaxNumber: | 3192331630 | ||||||||
| Practice Location | |||||||||
| Address1: | 1825 LOGAN AVE | ||||||||
| Address2: | |||||||||
| City: | WATERLOO | ||||||||
| State: | IA | ||||||||
| PostalCode: | 50703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3192353886 | ||||||||
| FaxNumber: | 3192331630 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2006 | ||||||||
| LastUpdateDate: | 12/10/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | D-074832 | IA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 2062018 | 05 | IA | MEDICAID | 55001 | 01 | IA | WELLMARK INS PLAN | OTHER | 42141730780 | 01 | IA | JOHN DEERE HEALTH INS | OTHER | 3062018 | 05 | IA | MEDICAID |