Provider Demographics
NPI:1255316808
Name:WILSON, JASON EARL (CRNA)
Entity Type:Individual
Prefix:MR
First Name:JASON
Middle Name:EARL
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 1:242 DEERFOOT DR
Mailing Address - Street 2:
Mailing Address - City:LONDON
Mailing Address - State:KY
Mailing Address - Zip Code:40741-8849
Mailing Address - Country:US
Mailing Address - Phone:606-862-2686
Mailing Address - Fax:
Practice Address - Street 1:242 DEERFOOT DR
Practice Address - Street 2:
Practice Address - City:LONDON
Practice Address - State:KY
Practice Address - Zip Code:40741-8849
Practice Address - Country:US
Practice Address - Phone:606-862-2686
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-07
Last Update Date:2013-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP3143422367500000X
KY3004775367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLG3425OtherBCBS
FL306753000Medicaid
KYP400024407Medicare PIN
FLG3425FMedicare ID - Type Unspecified
FL306753000Medicaid