Healthcare Provider Details

I. General information

NPI: 1427150473
Provider Name (Legal Business Name): ROBERT A WILSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 WASHBURN PLACE
LOPEZ ISLAND WA
98261
US

IV. Provider business mailing address

1211 24TH ST
ANACORTES WA
98221-2557
US

V. Phone/Fax

Practice location:
  • Phone: 360-468-2245
  • Fax:
Mailing address:
  • Phone: 360-299-1300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD00032057
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: