1497727218 NPI number — GWEN WILSON PA

Table of content: GWEN WILSON PA (NPI 1497727218)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497727218 NPI number — GWEN WILSON PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILSON
Provider First Name:
GWEN
Provider Middle Name:
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:
1497727218
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1901 REDROCK DR
Provider Second Line Business Mailing Address:
PFS DEPT
Provider Business Mailing Address City Name:
GALLUP
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87301-5683
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-863-7000
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2111 COLLEGE DR
Provider Second Line Business Practice Location Address:
REHOBOTH MCKINLEY CHRISTIAN HEALTH CARE SERVICES
Provider Business Practice Location Address City Name:
GALLUP
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87301-5600
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-863-1820
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/06/2006

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:  88-PA-01 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 326240 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00093518 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: 10002165 . This is a "LOVELACE HEALTH/SALUD" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: PROVP16800 . This is a "MOLINA" identifier . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com