Provider Demographics
NPI:1134113087
Name:WILSON, LISA GIBSON (CRNA)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:GIBSON
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:PO BOX 11407
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35246-1428
Mailing Address - Country:US
Mailing Address - Phone:601-936-0682
Mailing Address - Fax:
Practice Address - Street 1:54 SERGEANT PRENTISS DR
Practice Address - Street 2:
Practice Address - City:NATCHEZ
Practice Address - State:MS
Practice Address - Zip Code:39120-4726
Practice Address - Country:US
Practice Address - Phone:601-443-2100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-07
Last Update Date:2008-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR818593367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSF28963Medicare UPIN
MS430003076Medicare PIN