Provider Demographics
NPI:1992985998
Name:WILKS, LANCE A (CRNA)
Entity type:Individual
Prefix:
First Name:LANCE
Middle Name:A
Last Name:WILKS
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4916 OVERTON PLZ
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76109-4415
Mailing Address - Country:US
Mailing Address - Phone:817-334-0530
Mailing Address - Fax:817-877-0350
Practice Address - Street 1:4916 OVERTON PLZ
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76109-4415
Practice Address - Country:US
Practice Address - Phone:817-334-0530
Practice Address - Fax:817-877-0350
Is Sole Proprietor?:No
Enumeration Date:2007-11-07
Last Update Date:2009-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX698485367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered