Provider Demographics
NPI:1770599615
Name:WILSON, MARY A (CRNA)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:A
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 1:210 N TUSTIN AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92705-3807
Mailing Address - Country:US
Mailing Address - Phone:714-347-1010
Mailing Address - Fax:714-647-1245
Practice Address - Street 1:10841 WHITE OAK AVE
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-3817
Practice Address - Country:US
Practice Address - Phone:909-581-6400
Practice Address - Fax:909-581-6418
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2021-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANA 2575367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ26809ZMedicare PIN
CACA244894 (RESTFUL)Medicare PIN
CACJ504AMedicare PIN
CA430079654Medicare PIN
CACA244893 (RESTFUL)Medicare PIN