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NPI Code Detail

MEDICARE: MR. CARLAN A WILSON JR. CRNA

MEDICARE: MR. CARLAN A WILSON JR. 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 Anesthetist050274TN

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2HBLS1OTHERIDBLUE CROSS

General Provider Information

NPI Number : 1326199092
Entity Type Code : Individual
Provider Name (Legal Business Name) : MR. CARLAN A WILSON JR. CRNA
Provider Business Mailing Address
First Line : 1001 E BROADWAY ST STOP 2
Second Line : PMB 629
City : MISSOULA
State : MT
Zip : 59802-4914
Country : US
Telephone Number : 239-285-5858
Fax Number :
Provider Business Practice Location Address
First Line : 607 W MAIN ST
Second Line :
City : GRANGEVILLE
State : ID
Zip : 83530-1345
Country : US
Telephone Number : 208-983-1700
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 01/16/2007
Last Update Date : 08/04/2011

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