Provider Demographics
NPI:1891707360
Name:WILSON, REGENIA L (CRNA)
Entity Type:Individual
Prefix:
First Name:REGENIA
Middle Name:L
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 1:4283 N NINES RIDGE LN
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-1866
Mailing Address - Country:US
Mailing Address - Phone:208-345-5830
Mailing Address - Fax:208-345-5830
Practice Address - Street 1:1000 STATE ST
Practice Address - Street 2:
Practice Address - City:MCCALL
Practice Address - State:ID
Practice Address - Zip Code:83638-3704
Practice Address - Country:US
Practice Address - Phone:208-634-2221
Practice Address - Fax:208-634-7112
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDRNA109367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID89250OtherBLUE CROSS GROUP #
ID000010017281OtherREGENCE
IDA4092OtherBLUE CROSS
ID131312Medicare Oscar/Certification