Basic Information
| Provider Information | |||||||||
| NPI: | 1659366573 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCCOLL | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1308 | ||||||||
| Address2: | |||||||||
| City: | KINGSPORT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376621308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4232243460 | ||||||||
| FaxNumber: | 4232243465 | ||||||||
| Practice Location | |||||||||
| Address1: | 135 W RAVINE RD | ||||||||
| Address2: | SUITE 5B | ||||||||
| City: | KINGSPORT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376603847 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4232243460 | ||||||||
| FaxNumber: | 4232243465 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2005 | ||||||||
| LastUpdateDate: | 08/17/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 9531 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 261962 | 01 | ANTHEM BCBS | OTHER | 3607752 | 05 | TN | MEDICAID | 2603073000 | 05 | WV | MEDICAID | 74299447 | 01 | KY | KY MEDICAID | OTHER | 3046122 | 01 | BLUE SHIELD OF TN | OTHER | 8922837 | 05 | VA | MEDICAID | 00013859 | 01 | NHC CARE ADMINISTRATORS | OTHER | TN0100 | 01 | JOHN DEERE | OTHER |