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General NPI Number Information
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NPI Number | 1285638999
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Entity Type | Individual
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Provider Name | GLEN P WILSON M.D.
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Gender | Male
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Dates
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Enumeration Date | 06/09/2005
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Last Update Date | 10/30/2024
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Provider Practice Location Address
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Address Line | 4901 LANG AVE NE
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City | ALBUQUERQUE
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State | NM
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Zip | 87109-4495
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Country | US
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Telephone | 505-842-8171
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Fax | 505-857-3877
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Provider Business Mailing Address
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Address Line | 800 BRADBURY DR SE STE 116
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City | ALBUQUERQUE
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State | NM
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Zip | 87106-4310
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Country | US
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Telephone | 505-272-1476
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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 | 2085R0202X
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Taxonomy Name | Diagnostic Radiology Physician
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License Number | 2000-314
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License Number State | NM
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