Basic Information
| Provider Information | |||||||||
| NPI: | 1881717866 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WALD | ||||||||
| FirstName: | GINA | ||||||||
| MiddleName: | LYNN | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 249 | ||||||||
| Address2: | |||||||||
| City: | LONGVIEW | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986327154 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604142048 | ||||||||
| FaxNumber: | 3605756749 | ||||||||
| Practice Location | |||||||||
| Address1: | 1615 DELAWARE ST | ||||||||
| Address2: | |||||||||
| City: | LONGVIEW | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986322310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604142048 | ||||||||
| FaxNumber: | 3605756749 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/06/2007 | ||||||||
| LastUpdateDate: | 11/14/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | RN00170658 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 0223024 | 01 | WA | LABOR & INDUSTRIES | OTHER | RN597396 | 01 | CA | RN LICENSE # | OTHER | 8944886 | 01 | WA | CRIME VICTIMS | OTHER | RN00170658 | 01 | WA | WA RN LICENSE | OTHER | 9653361 | 05 | WA | MEDICAID | AP30007691 | 01 | WA | WA ARNP LICENSE | OTHER |