Provider Demographics
NPI:1366604654
Name:WILSON, CHRISTOPHER DALE (CRNA)
Entity type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:DALE
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 1:611 ALCORN DR
Mailing Address - Street 2:
Mailing Address - City:CORINTH
Mailing Address - State:MS
Mailing Address - Zip Code:38834-9321
Mailing Address - Country:US
Mailing Address - Phone:662-293-1440
Mailing Address - Fax:662-293-4213
Practice Address - Street 1:611 ALCORN DR
Practice Address - Street 2:
Practice Address - City:CORINTH
Practice Address - State:MS
Practice Address - Zip Code:38834-9321
Practice Address - Country:US
Practice Address - Phone:662-293-1440
Practice Address - Fax:662-293-4213
Is Sole Proprietor?:No
Enumeration Date:2008-06-27
Last Update Date:2008-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR879347367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered