1336234277 NPI number — MS. CHRISTINE WILSON P.A.-C.

Table of content: MS. CHRISTINE WILSON P.A.-C. (NPI 1336234277)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336234277 NPI number — MS. CHRISTINE WILSON P.A.-C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILSON
Provider First Name:
CHRISTINE
Provider Middle Name:
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
P.A.-C.
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:
1336234277
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/29/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
402 N 4TH STREET
Provider Second Line Business Mailing Address:
SUITE 202
Provider Business Mailing Address City Name:
YAKIMA
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98901-0190
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-248-3782
Provider Business Mailing Address Fax Number:
503-588-0531

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3896 BEVERLY AVE. SE
Provider Second Line Business Practice Location Address:
BLDG. J, STE. 40
Provider Business Practice Location Address City Name:
SALEM
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97305-1374
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-588-0076
Provider Business Practice Location Address Fax Number:
503-588-0531
Provider Enumeration Date:
10/04/2006

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:  PA01463 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363A00000X , with the licence number: PA15054 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: PA01463 . This is a "MEDICAL LICENSE OREGON" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".




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