Healthcare Provider Details

I. General information

NPI: 1508824467
Provider Name (Legal Business Name): WILSON FULLA BERNALES M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2006
Last Update Date: 12/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

428 S DURBIN ST SUITE 104
CASPER WY
82601-2818
US

IV. Provider business mailing address

428 S DURBIN ST STE 104
CASPER WY
82601-2818
US

V. Phone/Fax

Practice location:
  • Phone: 307-337-4284
  • Fax: 307-462-0922
Mailing address:
  • Phone: 307-337-4284
  • Fax: 307-462-0922

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License NumberC1-0007844
License Number StateDE
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number7632A
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: