Provider Demographics
NPI:1669428447
Name:ALLEN, JOHN WYNN (CRNA)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:WYNN
Last Name:ALLEN
Suffix:
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 7096
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95267-0096
Mailing Address - Country:US
Mailing Address - Phone:209-956-7725
Mailing Address - Fax:209-956-7733
Practice Address - Street 1:2755 HERNDON AVE
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:CA
Practice Address - Zip Code:93611-6800
Practice Address - Country:US
Practice Address - Phone:559-324-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-25
Last Update Date:2013-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANA572367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARN2929100Medicaid
CANA572OtherBS OF CA
CA430079068OtherRAILROAD MEDICARE
CAZZZ20692ZMedicare PIN
CABN794XMedicare PIN
CABN794WMedicare PIN
CA430079068OtherRAILROAD MEDICARE