Provider Demographics
NPI:1255540340
Name:CONWELL, PHILLIP JR (CRNA)
Entity type:Individual
Prefix:
First Name:PHILLIP
Middle Name:
Last Name:CONWELL
Suffix:JR
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 937
Mailing Address - Street 2:
Mailing Address - City:MENDOCINO
Mailing Address - State:CA
Mailing Address - Zip Code:95460-0937
Mailing Address - Country:US
Mailing Address - Phone:707-813-7639
Mailing Address - Fax:707-937-2659
Practice Address - Street 1:700 RIVER DR
Practice Address - Street 2:
Practice Address - City:FORT BRAGG
Practice Address - State:CA
Practice Address - Zip Code:95437-5403
Practice Address - Country:US
Practice Address - Phone:707-961-1234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARN405621163W00000X
CA1064367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1064OtherCALIFORNIA BOARD OF REGISTERED NURSING