Basic Information
| Provider Information | |||||||||
| NPI: | 1790881761 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WISCOMBE | ||||||||
| FirstName: | GARY | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1727 RED BARN RD | ||||||||
| Address2: | |||||||||
| City: | SPRINGVILLE | ||||||||
| State: | UT | ||||||||
| PostalCode: | 846633231 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8014919337 | ||||||||
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| Practice Location | |||||||||
| Address1: | 10011 CENTENNIAL PKWY | ||||||||
| Address2: | |||||||||
| City: | SANDY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840704156 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8019939527 | ||||||||
| FaxNumber: | 8017335872 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 0225185-4406 | UT | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 02251854400001 | 01 | UT | BCBS | OTHER | 22332 | 01 | UT | HEALTHY U | OTHER | 72748 | 01 | UT | PEHP | OTHER | QM0000076551 | 01 | UT | ALTIUS | OTHER | 851248 | 01 | UT | DESERET MUTUAL | OTHER | 107028132101 | 01 | UT | IHC | OTHER | QMP0000033333378 | 01 | UT | MOLINA | OTHER |