Organization
WILDERNESS TRACE ANESTHESIA, PLLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MICHAEL T. MITCHELL (MANAGING MEMBER)
(843) 651-2624
Entity
Organization
Contact information
Practice address
210 S. 2ND ST., DANVILLE, KY 40422-1804
(859) 236-4008
(859) 236-5025
Mailing address
PO BOX 4860, MURRELLS INLET, SC 29576-2698
(843) 651-2624
(843) 357-4940
Taxonomy
Speciality
Code
Description
License number
State
367500000X
Certified Registered Nurse Anesthetist
Primary
0805370
KY
Other
Enumeration date
01/03/2012
Last updated
01/03/2012
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