Provider Demographics
NPI:1558723130
Name:WILSON, JOSEPH FRANK (CRNA)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:FRANK
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 1:3675 MARY LOU LN
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32934-8389
Mailing Address - Country:US
Mailing Address - Phone:321-243-5228
Mailing Address - Fax:
Practice Address - Street 1:2116 CRAIG RD
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54701-6149
Practice Address - Country:US
Practice Address - Phone:715-858-4500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-23
Last Update Date:2019-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9305671367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered