Provider Demographics
NPI:1538188032
Name:WILSON, BRUCE EDWARD (CRNA)
Entity type:Individual
Prefix:MR
First Name:BRUCE
Middle Name:EDWARD
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 1:3840 FAIRWAY DR
Mailing Address - Street 2:
Mailing Address - City:LAPEER
Mailing Address - State:MI
Mailing Address - Zip Code:48446-4302
Mailing Address - Country:US
Mailing Address - Phone:810-245-1838
Mailing Address - Fax:
Practice Address - Street 1:3840 FAIRWAY DR
Practice Address - Street 2:
Practice Address - City:LAPEER
Practice Address - State:MI
Practice Address - Zip Code:48446-4302
Practice Address - Country:US
Practice Address - Phone:810-245-1838
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704128332367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered