Healthcare Provider Details

I. General information

NPI: 1922146422
Provider Name (Legal Business Name): JERALD EDWIN WILSON CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/05/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

607 BEAMAN ST
CLINTON NC
28328-2603
US

IV. Provider business mailing address

PO BOX 1274 4343 HWY 701 NORTH
ELIZABETHTOWN NC
28337-1274
US

V. Phone/Fax

Practice location:
  • Phone: 910-592-8511
  • Fax: 910-590-8761
Mailing address:
  • Phone: 910-879-9886
  • Fax: 910-590-8761

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number029672
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: