Provider Demographics
NPI:1538100524
Name:WILSON, WANDA O (CRNA, PHD)
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:O
Last Name:WILSON
Suffix:
Gender:F
Credentials:CRNA, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2368 VICTORY PKWY
Mailing Address - Street 2:SUITE 501
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45206-2859
Mailing Address - Country:US
Mailing Address - Phone:513-872-7388
Mailing Address - Fax:513-872-7385
Practice Address - Street 1:234 GOODMAN ST
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45219-2364
Practice Address - Country:US
Practice Address - Phone:513-872-7388
Practice Address - Fax:513-872-7385
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2008-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN-111273367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000277561OtherANTHEM
KY74206079Medicaid
728038OtherBUCKEYE
OH0738974Medicaid
WI8200521Medicare ID - Type Unspecified
728038OtherBUCKEYE