Provider Demographics
NPI:1326199092
Name:WILSON, CARLAN A JR (CRNA)
Entity Type:Individual
Prefix:MR
First Name:CARLAN
Middle Name:A
Last Name:WILSON
Suffix:JR
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 1:1001 E BROADWAY ST STOP 2
Mailing Address - Street 2:PMB 629
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59802-4914
Mailing Address - Country:US
Mailing Address - Phone:239-285-5858
Mailing Address - Fax:
Practice Address - Street 1:607 W MAIN ST
Practice Address - Street 2:
Practice Address - City:GRANGEVILLE
Practice Address - State:ID
Practice Address - Zip Code:83530-1345
Practice Address - Country:US
Practice Address - Phone:208-983-1700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-16
Last Update Date:2011-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN050274367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807009800Medicaid
IDHBLS1OtherBLUE CROSS
ID131315Medicare Oscar/Certification
IDHBLS1OtherBLUE CROSS