Provider Demographics
NPI:1427370345
Name:WILSON, LARA NOEL (CRNA)
Entity Type:Individual
Prefix:MS
First Name:LARA
Middle Name:NOEL
Last Name:WILSON
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:LARA
Other - Middle Name:NOEL
Other - Last Name:DUNCAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:68 WEST DOMINION BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43214
Mailing Address - Country:US
Mailing Address - Phone:770-251-2060
Mailing Address - Fax:678-854-9235
Practice Address - Street 1:68 WEST DOMINION BOULEVARD
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43214
Practice Address - Country:US
Practice Address - Phone:770-251-2060
Practice Address - Fax:678-854-9235
Is Sole Proprietor?:No
Enumeration Date:2010-02-19
Last Update Date:2014-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN192709367500000X
OHRN.398740-COA.15479367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA842523571AMedicaid