Provider Demographics
NPI:1255323630
Name:WILSON, STEPHEN WESLEY (CRNA)
Entity Type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:WESLEY
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 1:3101 MORNINGSIDE CT
Mailing Address - Street 2:
Mailing Address - City:BALDWIN
Mailing Address - State:MD
Mailing Address - Zip Code:21013-9528
Mailing Address - Country:US
Mailing Address - Phone:410-557-6724
Mailing Address - Fax:410-557-4355
Practice Address - Street 1:10751 FALLS RD
Practice Address - Street 2:SUITE 425
Practice Address - City:LUTHERVILLE
Practice Address - State:MD
Practice Address - Zip Code:21093-4517
Practice Address - Country:US
Practice Address - Phone:410-583-2760
Practice Address - Fax:410-583-2759
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-22
Last Update Date:2007-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR063574367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
KCE3GLOtherBLUE CROSS BLUE SHIELD
S4320001OtherFEDERAL CAREFIRST
P00012294OtherMEDICARE RAILROAD
876ROtherMEDICARE