Healthcare Provider Details

I. General information

NPI: 1164569075
Provider Name (Legal Business Name): ELIZABETH PARKS WILDER CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2007
Last Update Date: 10/27/2020
Certification Date: 10/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3000 NEW BERN AVE
RALEIGH NC
27610-1231
US

IV. Provider business mailing address

PO BOX 18139
RALEIGH NC
27619-8139
US

V. Phone/Fax

Practice location:
  • Phone: 919-350-5645
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number146501
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: