Healthcare Provider Details

I. General information

NPI: 1730150673
Provider Name (Legal Business Name): GREGORY WILSON CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2006
Last Update Date: 04/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1515 UNION AVE
MOBERLY MO
65270-9407
US

IV. Provider business mailing address

1303 QUAIL HAVEN DR
MOBERLY MO
65270-3837
US

V. Phone/Fax

Practice location:
  • Phone: 573-686-5550
  • Fax:
Mailing address:
  • Phone: 573-686-5550
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number132362
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: