Provider Demographics
NPI:1902275142
Name:WILSON, JEREMY L (CRNA)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:L
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 1:2655 NORTHWINDS PKWY
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30009-2280
Mailing Address - Country:US
Mailing Address - Phone:770-643-5619
Mailing Address - Fax:678-352-4322
Practice Address - Street 1:888 SWIFT BLVD
Practice Address - Street 2:
Practice Address - City:RICHLAND
Practice Address - State:WA
Practice Address - Zip Code:99352-3514
Practice Address - Country:US
Practice Address - Phone:770-643-5619
Practice Address - Fax:678-352-4322
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-17
Last Update Date:2015-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN212544-6163W00000X
WAAP60607230367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse