Provider Demographics
NPI:1942247523
Name:CONERLY, WALTER K (CRNA)
Entity type:Individual
Prefix:
First Name:WALTER
Middle Name:K
Last Name:CONERLY
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:KEITH
Other - Middle Name:
Other - Last Name:CONERLY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CRNA
Mailing Address - Street 1:400 E 10TH ST
Mailing Address - Street 2:
Mailing Address - City:WACONIA
Mailing Address - State:MN
Mailing Address - Zip Code:55387-4552
Mailing Address - Country:US
Mailing Address - Phone:952-442-9770
Mailing Address - Fax:952-442-3630
Practice Address - Street 1:709 MIDDLE CREEK RD
Practice Address - Street 2:
Practice Address - City:SEVIERVILLE
Practice Address - State:TN
Practice Address - Zip Code:37862-5047
Practice Address - Country:US
Practice Address - Phone:952-442-9770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001150027367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4121942OtherBLUE CROSS OF TN
TN3636499Medicaid
TNP00346048Medicare ID - Type UnspecifiedRAILROAD MEDICARE
TN3636499Medicare ID - Type Unspecified