Healthcare Provider Details

I. General information

NPI: 1568712768
Provider Name (Legal Business Name): BLAKE LYNN WILSON CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/14/2012
Last Update Date: 08/13/2025
Certification Date: 08/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 CRADDUCK RD
ADA OK
74820-9400
US

IV. Provider business mailing address

1813 S 14TH ST
MCALESTER OK
74501-7220
US

V. Phone/Fax

Practice location:
  • Phone: 405-514-4786
  • Fax: 405-758-5582
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number89530
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: