Healthcare Provider Details

I. General information

NPI: 1073531687
Provider Name (Legal Business Name): MARY S WILSON N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 02/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

92-8691 LOTUS BLOSSOM LANE 6&7 92-8691 LOTUS BLOSSOM LANE 6&7
OCEAN VIEW HI
96737-9673
US

IV. Provider business mailing address

PO BOX 6065
OCEAN VIEW HI
96737-6065
US

V. Phone/Fax

Practice location:
  • Phone: 808-939-8100
  • Fax: 808-829-3672
Mailing address:
  • Phone: 808-939-8100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAPRN-1997
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: