Healthcare Provider Details

I. General information

NPI: 1316018955
Provider Name (Legal Business Name): NANCY LOU WILSON O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: NANCY LOU WILSON O.D.

II. Dates (important events)

Enumeration Date: 11/13/2006
Last Update Date: 03/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4505 BARRANCA PKWY STE C
IRVINE CA
92604-4797
US

IV. Provider business mailing address

4505 BARRANCA PKWY STE C
IRVINE CA
92604-4797
US

V. Phone/Fax

Practice location:
  • Phone: 949-857-0676
  • Fax: 949-857-2175
Mailing address:
  • Phone: 949-857-0676
  • Fax: 949-857-2175

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPT8049
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: