1235114653 NPI number — LAURA CHRISTINE WILSON CRNA

Table of content: LAURA CHRISTINE WILSON CRNA (NPI 1235114653)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235114653 NPI number — LAURA CHRISTINE WILSON CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILSON
Provider First Name:
LAURA
Provider Middle Name:
CHRISTINE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CRNA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1235114653
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/22/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

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

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7703 FLOYD CURL DR.
Provider Second Line Business Practice Location Address:
UTHSCSA
Provider Business Practice Location Address City Name:
SAN ANTONIO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78229-3900
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-567-2600
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/08/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 367500000X , with the licence number:  579886 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 85970U . This is a "BCBSTX" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".