Provider Demographics
NPI:1720233745
Name:WILSON, JOHN E JR (CRNA)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:E
Last Name:WILSON
Suffix:JR
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 1:278A BOWMAN LOOP
Mailing Address - Street 2:
Mailing Address - City:WEST POINT
Mailing Address - State:NY
Mailing Address - Zip Code:10996-1002
Mailing Address - Country:US
Mailing Address - Phone:410-371-3680
Mailing Address - Fax:
Practice Address - Street 1:WEST POINT ARMY MEDICAL CTR
Practice Address - Street 2:900 WASHINGTON RD
Practice Address - City:WEST POINT
Practice Address - State:NY
Practice Address - Zip Code:10996-0001
Practice Address - Country:US
Practice Address - Phone:845-938-0749
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-11-18
Last Update Date:2020-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR145444163W00000X, 367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse