Provider Demographics
NPI:1730186214
Name:WILSON, DIXIE HUDSON (CRNA)
Entity type:Individual
Prefix:
First Name:DIXIE
Middle Name:HUDSON
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 1:1340 HAL GREER BOULEVARD
Mailing Address - Street 2:ATTN: TAMMIE SILVA
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25701-3800
Mailing Address - Country:US
Mailing Address - Phone:304-526-2243
Mailing Address - Fax:304-522-9116
Practice Address - Street 1:1623 13TH AVE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25701-3845
Practice Address - Country:US
Practice Address - Phone:304-526-2243
Practice Address - Fax:304-522-9116
Is Sole Proprietor?:No
Enumeration Date:2005-06-30
Last Update Date:2012-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV20581367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS74205550Medicaid
OH0773837Medicaid
WV0067964000Medicaid
WV0067964000Medicaid
WVWI8205273Medicare PIN