Healthcare Provider Details

I. General information

NPI: 1720174345
Provider Name (Legal Business Name): TARA L WILSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TARA L THOMAS

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 12/22/2021
Certification Date: 12/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3660 PARK SIERRA DR SUITE 105
RIVERSIDE CA
92505-3071
US

IV. Provider business mailing address

P.O. BOX 2828
CORONA CA
92878-2828
US

V. Phone/Fax

Practice location:
  • Phone: 951-278-8870
  • Fax: 951-278-8913
Mailing address:
  • Phone: 951-278-8870
  • Fax: 951-278-8913

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberA80520
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: