Provider Demographics
NPI:1497854327
Name:WILSON, TAMI E (CRNA)
Entity Type:Individual
Prefix:
First Name:TAMI
Middle Name:E
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 1:141 N MAIN ST STE 205
Mailing Address - Street 2:
Mailing Address - City:BREWER
Mailing Address - State:ME
Mailing Address - Zip Code:04412-2055
Mailing Address - Country:US
Mailing Address - Phone:207-973-4519
Mailing Address - Fax:207-992-4132
Practice Address - Street 1:489 STATE ST
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-6616
Practice Address - Country:US
Practice Address - Phone:207-973-4519
Practice Address - Fax:207-992-4132
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2013-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME045382367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEME1856Medicare ID - Type Unspecified