Individual
JEREMIAH BRANDON WILSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
CRNA
Contact information
Practice address
1424 EAST FRONT, TYLER, TX 75702-8501
(903) 595-4144
Mailing address
PO BOX 130639, TYLER, TX 75713-0639
(903) 595-4144
Taxonomy
Speciality
Code
Description
License number
State
367500000X
Certified Registered Nurse Anesthetist
Primary
074369
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
178842402
—
TX
01
—
89118U
BLUE CROSS BLUE SHIELD
TX
Enumeration date
01/09/2007
Last updated
12/17/2008
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