1275656332 NPI number — RICHARD A WILSON MA

Table of content: (NPI 1275656332)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275656332 NPI number — RICHARD A WILSON MA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RICHARD A WILSON MA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1275656332
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
122 N RAYMOND RD
Provider Second Line Business Mailing Address:
STE 20
Provider Business Mailing Address City Name:
SPOKANE VALLEY
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
99206-6832
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-926-1770
Provider Business Mailing Address Fax Number:
509-228-9542

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
104 S FREYA ST STE 215B
Provider Second Line Business Practice Location Address:
ORANGE FLAG BLGD
Provider Business Practice Location Address City Name:
SPOKANE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
99202-6204
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-535-2048
Provider Business Practice Location Address Fax Number:
509-535-2046
Provider Enumeration Date:
04/06/2007

Additional Information

Authorized Official

Authorized Official Last Name:
WILSON
Authorized Official First Name:
RICHARD
Authorized Official Middle Name:
A
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
509-535-2048

Provider Taxonomy Codes

  • Taxonomy code: 101YM0800X , with the licence number:  LH00007082 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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