Provider Demographics
NPI:1245342344
Name:WILSON, JO LYNN (CRNA)
Entity type:Individual
Prefix:MS
First Name:JO
Middle Name:LYNN
Last Name:WILSON
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:MS
Other - First Name:JO
Other - Middle Name:LYNN
Other - Last Name:BORN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4916 OVERTON PLZ
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76109-4415
Mailing Address - Country:US
Mailing Address - Phone:817-529-1920
Mailing Address - Fax:817-334-0235
Practice Address - Street 1:800 12TH AVE
Practice Address - Street 2:STE. 100
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2518
Practice Address - Country:US
Practice Address - Phone:817-810-0600
Practice Address - Fax:817-236-1394
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2009-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX226528367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX162546901Medicaid
TX162546901Medicaid