Provider Demographics
NPI:1336225127
Name:WILSON, REBECCA LEE (CRNA)
Entity Type:Individual
Prefix:MRS
First Name:REBECCA
Middle Name:LEE
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 1:501 MORRIS ST
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25301-1326
Mailing Address - Country:US
Mailing Address - Phone:304-932-4166
Mailing Address - Fax:304-388-3604
Practice Address - Street 1:501 MORRIS ST
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25301
Practice Address - Country:US
Practice Address - Phone:304-388-6261
Practice Address - Fax:304-388-3604
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2017-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVAPRN27016-CRNA367500000X
WV32610367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0065260000Medicaid
WV4430069474OtherCAMC RAILROAD MEDICARE
WVW17297021Medicare ID - Type Unspecified