Healthcare Provider Details

I. General information

NPI: 1437533858
Provider Name (Legal Business Name): HEATHER MARIE WILSON D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MRS. HEATHER GARTIN

II. Dates (important events)

Enumeration Date: 07/15/2015
Last Update Date: 04/11/2025
Certification Date: 04/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 RAINBOW BLVD
EXCELSIOR SPRINGS MO
64024-1182
US

IV. Provider business mailing address

1700 RAINBOW BLVD
EXCELSIOR SPRINGS MO
64024-1182
US

V. Phone/Fax

Practice location:
  • Phone: 816-630-6722
  • Fax: 816-629-3636
Mailing address:
  • Phone: 816-630-6722
  • Fax: 816-629-3636

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number2022031656
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2022031656
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code202D00000X
TaxonomyIntegrative Medicine Physician
License Number2022031656
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: