Healthcare Provider Details

I. General information

NPI: 1972602969
Provider Name (Legal Business Name): EDITH DIANE WILSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2006
Last Update Date: 08/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 LILLY RD NE STE 175
OLYMPIA WA
98506-5179
US

IV. Provider business mailing address

615 LILLY RD NE STE 175
OLYMPIA WA
98506-5179
US

V. Phone/Fax

Practice location:
  • Phone: 360-486-6772
  • Fax: 360-486-6775
Mailing address:
  • Phone: 360-486-6772
  • Fax: 360-486-6775

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number5500A
License Number StateWY
# 2
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number36402
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: