Healthcare Provider Details

I. General information

NPI: 1801705207
Provider Name (Legal Business Name): WILLIAM SHANE WILSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/02/2026
Last Update Date: 09/02/2026
Certification Date: 09/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2805 E 19TH ST
VANCOUVER WA
98661-4614
US

IV. Provider business mailing address

2805 E 19TH ST
VANCOUVER WA
98661-4614
US

V. Phone/Fax

Practice location:
  • Phone: 360-255-5993
  • Fax: 360-768-5992
Mailing address:
  • Phone: 360-255-5993
  • Fax: 360-768-5992

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberLP00046353
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: