Provider Demographics
NPI:1730146309
Name:WILSON, CHARLES DERRICK (CRNA)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:DERRICK
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:PO BOX 661495
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35266-1495
Mailing Address - Country:US
Mailing Address - Phone:205-979-5882
Mailing Address - Fax:205-979-1248
Practice Address - Street 1:4800 48TH ST
Practice Address - Street 2:
Practice Address - City:VALLEY
Practice Address - State:AL
Practice Address - Zip Code:36854-3666
Practice Address - Country:US
Practice Address - Phone:334-756-1848
Practice Address - Fax:334-756-1854
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2011-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-044011367500000X
GARN065069367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51517977OtherBCBSAL PROVIDER #
GA000549381EMedicaid
AL051517977Medicaid
GA000549381CMedicaid
GA000549381DMedicaid
AL051517977Medicare ID - Type UnspecifiedPROVIDER #
R65399Medicare UPIN
AL051517977Medicaid
GA511I430088Medicare PIN