Provider Demographics
NPI:1174671853
Name:WILSON, TERRY LEE (CRNA)
Entity Type:Individual
Prefix:MR
First Name:TERRY
Middle Name:LEE
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 1:1050 DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:MAUSTON
Mailing Address - State:WI
Mailing Address - Zip Code:53948-1931
Mailing Address - Country:US
Mailing Address - Phone:608-847-6161
Mailing Address - Fax:
Practice Address - Street 1:1050 DIVISION ST
Practice Address - Street 2:
Practice Address - City:MAUSTON
Practice Address - State:WI
Practice Address - Zip Code:53948-1931
Practice Address - Country:US
Practice Address - Phone:608-847-6161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2175033367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43372200Medicaid
WIWILSOTEROtherMERCYCARE
WIWILSOTEROtherMERCYCARE
WIS47031Medicare UPIN