Provider Demographics
NPI:1922146422
Name:WILSON, JERALD EDWIN (CRNA)
Entity Type:Individual
Prefix:MR
First Name:JERALD
Middle Name:EDWIN
Last Name:WILSON
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1274
Mailing Address - Street 2:4343 HWY 701 NORTH
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:NC
Mailing Address - Zip Code:28337-1274
Mailing Address - Country:US
Mailing Address - Phone:910-879-9886
Mailing Address - Fax:910-590-8761
Practice Address - Street 1:607 BEAMAN ST
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:NC
Practice Address - Zip Code:28328-2603
Practice Address - Country:US
Practice Address - Phone:910-592-8511
Practice Address - Fax:910-590-8761
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC029672367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8050558Medicaid
NC8050558Medicaid