Healthcare Provider Details

I. General information

NPI: 1205418209
Provider Name (Legal Business Name): MICHAEL DANIEL WILSON DNAP, CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/28/2021
Last Update Date: 06/09/2021
Certification Date: 06/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 15TH ST
AUGUSTA GA
30912-0004
US

IV. Provider business mailing address

112 WARREN RD
AUGUSTA GA
30907-3755
US

V. Phone/Fax

Practice location:
  • Phone: 706-721-0211
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License NumberRN239744
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN239744
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: