MEDICARE: LAURA CHRISTINE 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	579886	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	85970U	OTHER	TX	BCBSTX

General Provider Information

NPI Number	:	1235114653
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAURA CHRISTINE WILSON CRNA

Provider Business Mailing Address
First Line	:	200 GARDENVIEW
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78213-1909
Country	:	US
Telephone Number	:	210-979-0945
Fax Number	:

Provider Business Practice Location Address
First Line	:	7703 FLOYD CURL DR.
Second Line	:	UTHSCSA
City	:	SAN ANTONIO
State	:	TX
Zip	:	78229-3900
Country	:	US
Telephone Number	:	210-567-2600
Fax Number	:

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

Provider Enumeration Date	:	12/08/2005
Last Update Date	:	10/22/2007

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