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NPI Code Detail

MEDICARE: MRS. LISA GIBSON WILSON CRNA

MEDICARE: MRS. LISA GIBSON 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
1367500000XCertified Registered Nurse AnesthetistR818593MS

General Provider Information

NPI Number : 1134113087
Entity Type Code : Individual
Provider Name (Legal Business Name) : MRS. LISA GIBSON WILSON CRNA
Provider Business Mailing Address
First Line : PO BOX 11407
Second Line :
City : BIRMINGHAM
State : AL
Zip : 35246-1428
Country : US
Telephone Number : 601-936-0682
Fax Number :
Provider Business Practice Location Address
First Line : 54 SERGEANT PRENTISS DR
Second Line :
City : NATCHEZ
State : MS
Zip : 39120-4726
Country : US
Telephone Number : 601-443-2100
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 09/07/2005
Last Update Date : 05/30/2008

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