Provider Demographics
NPI:1265478911
Name:WILSON, HEATHER (CRNA)
Entity Type:Individual
Prefix:MS
First Name:HEATHER
Middle Name:
Last Name:WILSON
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:PO BOX 1448
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91729-1448
Mailing Address - Country:US
Mailing Address - Phone:323-555-5555
Mailing Address - Fax:
Practice Address - Street 1:14850 ROSCOE BLVD
Practice Address - Street 2:
Practice Address - City:PANORAMA CITY
Practice Address - State:CA
Practice Address - Zip Code:91402-4618
Practice Address - Country:US
Practice Address - Phone:323-555-5555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2019-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANA#2955367500000X
CA2955367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CANA0029550OtherBLUE SHIELD
CARN5669950Medicaid
CAP00021359OtherRAILROAD MEDICARE
CARN5669950328OtherCALOPTIMA
CARN5669950328OtherCALOPTIMA
P83599Medicare UPIN
CANA0029550OtherBLUE SHIELD