Provider Demographics
NPI:1841296811
Name:WILSON, MARCIA H (CRNA)
Entity type:Individual
Prefix:
First Name:MARCIA
Middle Name:H
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 1:367 KNOLLWOOD DR
Mailing Address - Street 2:
Mailing Address - City:HAMPSTEAD
Mailing Address - State:NC
Mailing Address - Zip Code:28443-8440
Mailing Address - Country:US
Mailing Address - Phone:910-270-6163
Mailing Address - Fax:
Practice Address - Street 1:2131 S 17TH ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-7407
Practice Address - Country:US
Practice Address - Phone:910-343-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN-149702-L367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA543426Medicare ID - Type Unspecified