Provider Demographics
NPI: | 1134106289 |
---|---|
Name: | WILSON, BRUCE MICHAEL (CRNA) |
Entity Type: | Individual |
Prefix: | MR |
First Name: | BRUCE |
Middle Name: | MICHAEL |
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: | 800 N HIGHWAY 77 |
Mailing Address - Street 2: | STE 160 PMB#224 |
Mailing Address - City: | WAXAHACHIE |
Mailing Address - State: | TX |
Mailing Address - Zip Code: | 75165-1884 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 972-937-7240 |
Mailing Address - Fax: | 972-937-4255 |
Practice Address - Street 1: | 1405 W JEFFERSON ST |
Practice Address - Street 2: | |
Practice Address - City: | WAXAHACHIE |
Practice Address - State: | TX |
Practice Address - Zip Code: | 75165-2231 |
Practice Address - Country: | US |
Practice Address - Phone: | 972-937-7240 |
Practice Address - Fax: | 972-937-4255 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2005-12-29 |
Last Update Date: | 2007-07-09 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
TX | 253451 | 367500000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 367500000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
TX | 8C7847 | Medicare ID - Type Unspecified | 606K |
TX | 86845H | Medicare ID - Type Unspecified | 339K |
P42478 | Medicare UPIN |