Provider Demographics
NPI:1619996030
Name:WILSON, PAMALA LEA (CRNA)
Entity Type:Individual
Prefix:
First Name:PAMALA
Middle Name:LEA
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 1:4500 S GARNETT RD
Mailing Address - Street 2:STE 919
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74146-5229
Mailing Address - Country:US
Mailing Address - Phone:918-728-6145
Mailing Address - Fax:
Practice Address - Street 1:10502 N 110TH EAST AVE
Practice Address - Street 2:
Practice Address - City:OWASSO
Practice Address - State:OK
Practice Address - Zip Code:74055-6627
Practice Address - Country:US
Practice Address - Phone:918-728-6145
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2007-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0082268367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK24M728915Medicare PIN