1215955398 NPI number — REBEKAH JOY WILSON PA

Table of content: REBEKAH JOY WILSON PA (NPI 1215955398)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215955398 NPI number — REBEKAH JOY WILSON PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILSON
Provider First Name:
REBEKAH
Provider Middle Name:
JOY
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA
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:
1215955398
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/06/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3833 COON RAPIDS BLVD NW
Provider Second Line Business Mailing Address:
STE 100
Provider Business Mailing Address City Name:
COON RAPIDS
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55433-2577
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
763-427-8320
Provider Business Mailing Address Fax Number:
763-427-1243

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6043 HUDSON RD STE 220
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WOODBURY
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55125-1033
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-925-8200
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/17/2006

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: 363A00000X , with the licence number:  10006 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 42873700 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1045342 . This is a "PREFERRED ONE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 135410C029 . This is a "UCARE" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 477445100 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: HP54882 . This is a "HEALTHPARTNERS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 121502 . This is a "MEDICA" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 2378486 . This is a "AMERICA'S PPO" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 625T5WI . This is a "BCBS OF MN" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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