Healthcare Provider Details

I. General information

NPI: 1225175516
Provider Name (Legal Business Name): KAREN EVONNE WILSON M.S., R.D., PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2007
Last Update Date: 02/16/2024
Certification Date: 02/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8890 N UNION BLVD STE 220
COLORADO SPRINGS CO
80920-2701
US

IV. Provider business mailing address

2 S CASCADE AVE STE 140
COLORADO SPRINGS CO
80903-1604
US

V. Phone/Fax

Practice location:
  • Phone: 719-574-9191
  • Fax:
Mailing address:
  • Phone: 719-538-2900
  • Fax: 719-538-2990

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA.0004345
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: