Provider Demographics
NPI:1871580985
Name:WETHERHOLD, CAROLE B (CRNA)
Entity type:Individual
Prefix:
First Name:CAROLE
Middle Name:B
Last Name:WETHERHOLD
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1245 S CEDAR CREST BLVD
Mailing Address - Street 2:SUITE #301
Mailing Address - City:ALLENTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18103-6258
Mailing Address - Country:US
Mailing Address - Phone:610-402-9099
Mailing Address - Fax:610-402-9029
Practice Address - Street 1:17TH & CHEW STREET
Practice Address - Street 2:
Practice Address - City:ALLENTOWN
Practice Address - State:PA
Practice Address - Zip Code:18102
Practice Address - Country:US
Practice Address - Phone:610-402-9099
Practice Address - Fax:610-402-9029
Is Sole Proprietor?:No
Enumeration Date:2005-10-04
Last Update Date:2013-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN167771L163W00000X
PA019438367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0011679400004Medicaid
PA0994143OtherKHP CENTRAL
PA1567631OtherHIGHMARK
PA1567631OtherFIRST PRIORITY
PA2248292000OtherINDEP. BLUE CROSS
PA50026716OtherCAPITAL ADVANTAGE
PA82872OtherGEISINGER
PA7418819OtherAETNA
PA1579546OtherGATEWAY
PACAQHOther11267076
PA010770QCYMedicare PIN
PA82872OtherGEISINGER
PA2248292000OtherINDEP. BLUE CROSS