Provider Demographics
NPI:1396846499
Name:WILSON, RANDALL J (CRNA)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:J
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 1:6 HARBORVIEW CT NE
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:AL
Mailing Address - Zip Code:35601-1630
Mailing Address - Country:US
Mailing Address - Phone:256-642-1344
Mailing Address - Fax:256-353-8477
Practice Address - Street 1:1300 S MONTGOMERY AVE
Practice Address - Street 2:
Practice Address - City:SHEFFIELD
Practice Address - State:AL
Practice Address - Zip Code:35660-6334
Practice Address - Country:US
Practice Address - Phone:256-386-4005
Practice Address - Fax:256-386-4685
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1083888367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
P91110Medicare UPIN