Healthcare Provider Details

I. General information

NPI: 1104579531
Provider Name (Legal Business Name): JEFFREY TODD WILSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/26/2022
Last Update Date: 01/26/2022
Certification Date: 01/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7943 HARGIS ST NW
OLYMPIA WA
98502-9645
US

IV. Provider business mailing address

7943 HARGIS ST NW
OLYMPIA WA
98502-9645
US

V. Phone/Fax

Practice location:
  • Phone: 360-480-1410
  • Fax:
Mailing address:
  • Phone: 360-480-1410
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZS0410X
TaxonomySurgical Technologist
License Number00002628
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: