Provider Demographics
NPI:1356988547
Name:WILSON, MATTHEW ROYAL (CRNA)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:ROYAL
Last Name:WILSON
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 1:555 KINGSLEY TRL
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48304-2317
Mailing Address - Country:US
Mailing Address - Phone:248-736-2037
Mailing Address - Fax:
Practice Address - Street 1:36475 FIVE MILE RD
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48154-1971
Practice Address - Country:US
Practice Address - Phone:734-655-4800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-06
Last Update Date:2019-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704299657367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered