MEDICARE: GREGORY WILSON CRNA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	367500000X	Certified Registered Nurse Anesthetist	132362	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	125164	OTHER	MO	MO BCBS

General Provider Information

NPI Number	:	1730150673
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GREGORY WILSON CRNA

Provider Business Mailing Address
First Line	:	1303 QUAIL HAVEN DR
Second Line	:
City	:	MOBERLY
State	:	MO
Zip	:	65270-3837
Country	:	US
Telephone Number	:	573-686-5550
Fax Number	:

Provider Business Practice Location Address
First Line	:	1515 UNION AVE
Second Line	:
City	:	MOBERLY
State	:	MO
Zip	:	65270-9407
Country	:	US
Telephone Number	:	573-686-5550
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/30/2006
Last Update Date	:	04/02/2008

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