Basic Information
| Provider Information | |||||||||
| NPI: | 1902967938 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | CRAIG | ||||||||
| MiddleName: | RICHARD | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4150 V ST. PSSB SUITE 1200 | ||||||||
| Address2: | UCD HEALTH SYSTEM MED/ANESTHESIOLOGY & PAIN | ||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958171460 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9167347985 | ||||||||
| FaxNumber: | 9167342975 | ||||||||
| Practice Location | |||||||||
| Address1: | 4150 V ST. PSSB SUITE 1200 | ||||||||
| Address2: | UCD HEALTH SYSTEM MED/ANESTHESIOLOGY & PAIN | ||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958171460 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9167347985 | ||||||||
| FaxNumber: | 9167342975 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/13/2006 | ||||||||
| LastUpdateDate: | 09/17/2012 | ||||||||
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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 | NA46630 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | RN4460840 | 05 | CA | MEDICAID |