Provider Demographics
NPI:1134106289
Name:WILSON, BRUCE MICHAEL (CRNA)
Entity type:Individual
Prefix:MR
First Name:BRUCE
Middle Name:MICHAEL
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 1:800 N HIGHWAY 77
Mailing Address - Street 2:STE 160 PMB#224
Mailing Address - City:WAXAHACHIE
Mailing Address - State:TX
Mailing Address - Zip Code:75165-1884
Mailing Address - Country:US
Mailing Address - Phone:972-937-7240
Mailing Address - Fax:972-937-4255
Practice Address - Street 1:1405 W JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:WAXAHACHIE
Practice Address - State:TX
Practice Address - Zip Code:75165-2231
Practice Address - Country:US
Practice Address - Phone:972-937-7240
Practice Address - Fax:972-937-4255
Is Sole Proprietor?:No
Enumeration Date:2005-12-29
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX253451367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8C7847Medicare ID - Type Unspecified606K
TX86845HMedicare ID - Type Unspecified339K
P42478Medicare UPIN