Healthcare Provider Details

I. General information

NPI: 1447561535
Provider Name (Legal Business Name): ANNA BABAYAN WILSON D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/23/2010
Last Update Date: 10/31/2023
Certification Date: 08/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

117 NEAL ST STE A
GRASS VALLEY CA
95945-6705
US

IV. Provider business mailing address

117 NEAL ST STE A
GRASS VALLEY CA
95945-6705
US

V. Phone/Fax

Practice location:
  • Phone: 530-273-2720
  • Fax: 530-273-2770
Mailing address:
  • Phone: 530-273-2720
  • Fax: 530-273-2770

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number20A17564
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number5315046210
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: