Healthcare Provider Details

I. General information

NPI: 1013932185
Provider Name (Legal Business Name): DIANE EH WILSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2006
Last Update Date: 09/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1937 W 5700 S
ROY UT
84067-2303
US

IV. Provider business mailing address

1055 N 500 W
PROVO UT
84604-3305
US

V. Phone/Fax

Practice location:
  • Phone: 801-773-9380
  • Fax:
Mailing address:
  • Phone: 801-375-8858
  • Fax: 801-418-0941

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number1832651205
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: