Provider Demographics
NPI:1033167028
Name:WILSON, ADAM ABDUL ALIM (CRNA)
Entity Type:Individual
Prefix:MR
First Name:ADAM
Middle Name:ABDUL ALIM
Last Name:WILSON
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 EAST BLVD
Mailing Address - Street 2:
Mailing Address - City:ELKHART
Mailing Address - State:IN
Mailing Address - Zip Code:46514-2483
Mailing Address - Country:US
Mailing Address - Phone:574-524-8130
Mailing Address - Fax:
Practice Address - Street 1:600 EAST BLVD
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46514-2483
Practice Address - Country:US
Practice Address - Phone:574-524-8130
Practice Address - Fax:574-524-8138
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-04
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN. 325391163W00000X
OH14336 NA367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0083386Medicaid
OHRN.325391OtherRN NURSING LICENS
OH0083386Medicaid
OHH191500Medicare PIN