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General NPI Number Information
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NPI Number | 1003034018
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Entity Type | Individual
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Provider Name | LYSTRA B WILSON-CELESTINE MD
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Gender | Female
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Dates
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Enumeration Date | 04/23/2007
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Last Update Date | 05/29/2018
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Provider Practice Location Address
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Address Line | 280 SIERRA COLLEGE DR STE 115
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City | GRASS VALLEY
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State | CA
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Zip | 95945
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Country | US
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Telephone | 530-477-3119
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Fax | 530-274-2077
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Provider Business Mailing Address
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Address Line | 3400 DATA DR ATTN: CREDENTIALING/PAYER ENROLLMENT
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City | RANCHO CORDOVA
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State | CA
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Zip | 95670-7956
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207V00000X
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Taxonomy Name | Obstetrics & Gynecology Physician
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License Number | MD00048034
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License Number State | WA
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