1639142185 NPI number — NANCY L WILSON M.D.

Table of content: NANCY L WILSON M.D. (NPI 1639142185)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639142185 NPI number — NANCY L WILSON M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILSON
Provider First Name:
NANCY
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1639142185
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/11/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2400 S. MINNESOTA AVE
Provider Second Line Business Mailing Address:
STE 100
Provider Business Mailing Address City Name:
SIOUX FALLS
Provider Business Mailing Address State Name:
SD
Provider Business Mailing Address Postal Code:
57105-3762
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
605-322-7510
Provider Business Mailing Address Fax Number:
605-322-6475

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4400 W 69TH ST
Provider Second Line Business Practice Location Address:
STE 1500
Provider Business Practice Location Address City Name:
SIOUX FALLS
Provider Business Practice Location Address State Name:
SD
Provider Business Practice Location Address Postal Code:
57108-8170
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
605-322-5700
Provider Business Practice Location Address Fax Number:
605-322-5704
Provider Enumeration Date:
02/07/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2084P0800X , with the licence number:  1225 , registered in the state of SD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 241638 . This is a "MIDLANDS CHOICE" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 7101810 , issued by the state of ( SD ) . This identifiers is of the category "MEDICAID".
  • Identifier: 9217282 . This is a "DAKOTACARE" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: HP40082 . This is a "HEALTHPARTNERS" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 040121002 . This is a "PRIMEWEST" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 12200 , issued by the state of ( ND ) . This identifiers is of the category "MEDICAID".
  • Identifier: 235562 . This is a "ARAZ/ AMERICA'S PPO" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 478R1WI . This is a "CC SYSTEMS/ BLUE PLUS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 1999862 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 412991012874 . This is a "PREFERRED ONE" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 46022474352 , issued by the state of ( NE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 57108C029 . This is a "WPS TRICARE" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 370624200 . This is a "DEPT OF LABOR" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 4994862 . This is a "BLUE CROSS" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 30853 . This is a "SANFORD HEALTH PLAN" identifier , issued by the state of ( SD ) . This identifiers is of the category "OTHER".
  • Identifier: 410862100 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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