MEDICARE: KATHY WILSON M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207V00000X	Obstetrics & Gynecology Physician	A119319	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1245490721
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATHY WILSON M.D.

Provider Business Mailing Address
First Line	:	2683 PACIFIC AVE
Second Line	:	SUITE A
City	:	LONG BEACH
State	:	CA
Zip	:	90806-2610
Country	:	US
Telephone Number	:	323-404-4884
Fax Number	:

Provider Business Practice Location Address
First Line	:	2683 PACIFIC AVE
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90806-2610
Country	:	US
Telephone Number	:	323-404-4884
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/10/2008
Last Update Date	:	01/14/2016

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