Healthcare Provider Details

I. General information

NPI: 1255536710
Provider Name (Legal Business Name): JOHN WILSON CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/15/2007
Last Update Date: 01/13/2022
Certification Date: 01/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 W ASH ST
DEMING NM
88030-4000
US

IV. Provider business mailing address

2304 SEDONA HILLS PKWY
LAS CRUCES NM
88011-4139
US

V. Phone/Fax

Practice location:
  • Phone: 575-546-5800
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberCRNA-01201
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: