Provider Demographics
NPI:1255481370
Name:PHILLIPS, WILKERSON P (CRNA)
Entity type:Individual
Prefix:MR
First Name:WILKERSON
Middle Name:P
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1764 WEDGWOOD DR
Mailing Address - Street 2:
Mailing Address - City:HARVEY
Mailing Address - State:LA
Mailing Address - Zip Code:70058-7436
Mailing Address - Country:US
Mailing Address - Phone:504-328-4079
Mailing Address - Fax:
Practice Address - Street 1:1601 PERDIDO ST
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70112-1262
Practice Address - Country:US
Practice Address - Phone:504-568-0811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2009-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAPO1534367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1543993Medicaid
LA3A385C734Medicare PIN
LAP00637255Medicare PIN