MEDICARE: JACOB WILSON CRNA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	367500000X	Certified Registered Nurse Anesthetist	126589	WV

General Provider Information

NPI Number	:	1073447363
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACOB WILSON CRNA

Provider Business Mailing Address
First Line	:	2106 ENSLOW BLVD
Second Line	:
City	:	HUNTINGTON
State	:	WV
Zip	:	25701-4916
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2900 1ST AVE
Second Line	:
City	:	HUNTINGTON
State	:	WV
Zip	:	25702-1241
Country	:	US
Telephone Number	:	304-625-1234
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/11/2026
Last Update Date	:	06/11/2026

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Directions to “ JACOB WILSON CRNA” Practice Location

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