1750325833 NPI number — TERESA K WILSON CRNA

Table of content: TERESA K WILSON CRNA (NPI 1750325833)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750325833 NPI number — TERESA K WILSON CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILSON
Provider First Name:
TERESA
Provider Middle Name:
K
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:
1750325833
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/02/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3354 CHANTARENE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PENSACOLA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32507-3549
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-455-0954
Provider Business Mailing Address Fax Number:
850-455-0954

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3354 CHANTARENE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PENSACOLA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32507-3549
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-455-0954
Provider Business Practice Location Address Fax Number:
850-455-0954
Provider Enumeration Date:
06/16/2006

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:  ARNP2989882 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 009982105 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 305132300 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 59170238 . This is a "BCBS" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 59170239 . This is a "BCBS" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: P00134519 . This is a "PALMETTO GBA-RR MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: G3172 . This is a "BCBS" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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