Provider Demographics
NPI:1801858535
Name:WILCOCK, ALLYN D (CRNA)
Entity Type:Individual
Prefix:
First Name:ALLYN
Middle Name:D
Last Name:WILCOCK
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 1:36410 SE ISLEY ST
Mailing Address - Street 2:
Mailing Address - City:SNOQUALMIE
Mailing Address - State:WA
Mailing Address - Zip Code:98065-8983
Mailing Address - Country:US
Mailing Address - Phone:206-330-6722
Mailing Address - Fax:425-256-3250
Practice Address - Street 1:7829 CENTER BLVE STE 310
Practice Address - Street 2:
Practice Address - City:SNOQUALMIE
Practice Address - State:WA
Practice Address - Zip Code:98065
Practice Address - Country:US
Practice Address - Phone:206-330-6722
Practice Address - Fax:425-256-3250
Is Sole Proprietor?:No
Enumeration Date:2006-04-06
Last Update Date:2017-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN00157281163W00000X
WAAP30006926367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8940597OtherL & I CRIME VICTIMS
WA52822UOtherREGENCE BLUESHIELD
WA9644782Medicaid
WA0197111OtherLABOR & INDUSTRY
WA8940597OtherL & I CRIME VICTIMS
WAQ65038Medicare UPIN