Provider Demographics
NPI:1649359548
Name:WILBUR, WAYNE FRANCIS (CRNA)
Entity type:Individual
Prefix:MR
First Name:WAYNE
Middle Name:FRANCIS
Last Name:WILBUR
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 1:57 PROSPECT ST
Mailing Address - Street 2:
Mailing Address - City:NANTUCKET
Mailing Address - State:MA
Mailing Address - Zip Code:02554-2799
Mailing Address - Country:US
Mailing Address - Phone:774-563-1876
Mailing Address - Fax:401-826-0410
Practice Address - Street 1:57 PROSPECT ST
Practice Address - Street 2:
Practice Address - City:NANTUCKET
Practice Address - State:MA
Practice Address - Zip Code:02554-2799
Practice Address - Country:US
Practice Address - Phone:774-563-1876
Practice Address - Fax:401-826-0410
Is Sole Proprietor?:No
Enumeration Date:2006-11-03
Last Update Date:2010-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA199070367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MANA1102OtherBCBS
1649359548OtherFALLON
P00214045OtherRAILRAOD
MAJX2430Medicare PIN
MANA110201Medicare PIN
P00214045OtherRAILRAOD
MAJX2772Medicare PIN