Basic Information
| Provider Information | |||||||||
| NPI: | 1730146309 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | DERRICK | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 661495 | ||||||||
| Address2: | |||||||||
| City: | BIRMINGHAM | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352661495 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2059795882 | ||||||||
| FaxNumber: | 2059791248 | ||||||||
| Practice Location | |||||||||
| Address1: | 4800 48TH ST | ||||||||
| Address2: | |||||||||
| City: | VALLEY | ||||||||
| State: | AL | ||||||||
| PostalCode: | 368543666 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3347561848 | ||||||||
| FaxNumber: | 3347561854 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/27/2006 | ||||||||
| LastUpdateDate: | 09/27/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 1-044011 | AL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | RN065069 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 51517977 | 01 | AL | BCBSAL PROVIDER # | OTHER | 000549381E | 05 | GA | MEDICAID | 051517977 | 05 | AL | MEDICAID | 000549381C | 05 | GA | MEDICAID | 000549381D | 05 | GA | MEDICAID |