Individual
CHARLES DERRICK WILSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
CRNA
Contact information
Practice address
4800 48TH ST, VALLEY, AL 36854-3666
(334) 756-1848
(334) 756-1854
Mailing address
PO BOX 661495, BIRMINGHAM, AL 35266-1495
(205) 979-5882
(205) 979-1248
Taxonomy
Speciality
Code
Description
License number
State
367500000X
Certified Registered Nurse Anesthetist
1-044011
AL
367500000X
Certified Registered Nurse Anesthetist
Primary
RN065069
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
000549381C
—
GA
05
—
000549381D
—
GA
05
—
000549381E
—
GA
05
—
051517977
—
AL
01
—
51517977
BCBSAL PROVIDER #
AL
Enumeration date
04/27/2006
Last updated
09/27/2011
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