Provider Demographics
NPI:1114994241
Name:WILPS, MIRIAM C (CRNA)
Entity Type:Individual
Prefix:
First Name:MIRIAM
Middle Name:C
Last Name:WILPS
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 MOUNT WOOD RD
Mailing Address - Street 2:
Mailing Address - City:WHEELING
Mailing Address - State:WV
Mailing Address - Zip Code:26003-2632
Mailing Address - Country:US
Mailing Address - Phone:304-233-2455
Mailing Address - Fax:304-233-6073
Practice Address - Street 1:601 COLLIERS WAY
Practice Address - Street 2:
Practice Address - City:WEIRTON
Practice Address - State:WV
Practice Address - Zip Code:26062-5014
Practice Address - Country:US
Practice Address - Phone:304-797-6543
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-08
Last Update Date:2013-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN220746L367500000X
WV54904367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1062424OtherWV WORKERS' COMP
WV270052997004OtherTRICARE
WV001964246OtherMSBCBS
WV0069251000Medicaid
PA101465372Medicaid
WV27005299701OtherBRICKSTREET
WV27005299700OtherWORKERS COMP
WV001718477OtherMSBCBS
WV0207026000Medicaid
WVDA0096OtherRR MEDICARE
WV001706470OtherMSBCBS
WV001706470OtherMSBCBS
WV1062424OtherWV WORKERS' COMP