Provider Demographics
NPI:1093883225
Name:WILSON, RONALD RAY (CRNA)
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:RAY
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 1:200 CLINIC DR
Mailing Address - Street 2:
Mailing Address - City:MADISONVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42431-1661
Mailing Address - Country:US
Mailing Address - Phone:270-825-7200
Mailing Address - Fax:
Practice Address - Street 1:900 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:MADISONVILLE
Practice Address - State:KY
Practice Address - Zip Code:42431-1644
Practice Address - Country:US
Practice Address - Phone:270-825-5100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2015-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY5043A367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000513977OtherBCBS PROVIDER NUMBER
KY74012543Medicaid
KYCRNA LICENSEOther5043A
000000513977OtherBCBS PROVIDER NUMBER
0903678Medicare PIN
KYP00466322Medicare PIN