Individual
MR. CARLAN A WILSON JR.
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
CRNA
Contact information
Practice address
607 W MAIN ST, GRANGEVILLE, ID 83530-1345
(208) 983-1700
Mailing address
1001 E BROADWAY ST STOP 2, PMB 629, MISSOULA, MT 59802-4914
(239) 285-5858
Taxonomy
Speciality
Code
Description
License number
State
367500000X
Certified Registered Nurse Anesthetist
Primary
050274
TN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
807009800
—
ID
01
—
HBLS1
BLUE CROSS
ID
Enumeration date
01/16/2007
Last updated
08/04/2011
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