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General NPI Number Information
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NPI Number | 1356535405
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Entity Type | Organization
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Legal Business Name | WESTERN ARIZONA FOOT & ANKLE
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Dates
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Enumeration Date | 08/31/2007
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Last Update Date | 10/10/2007
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Provider Practice Location Address
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Address Line | 1980 MESQUITE AVE SUITE 103
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City | LAKE HAVASU CITY
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State | AZ
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Zip | 86403-7713
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Country | US
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Telephone | 928-680-4934
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Fax | 928-505-4416
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Provider Business Mailing Address
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Address Line | 1980 MESQUITE AVE SUITE 103
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City | LAKE HAVASU CITY
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State | AZ
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Zip | 86403-7713
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Country | US
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Telephone | 928-680-4934
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Fax | 928-505-4416
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Authorized Official
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Title or Position | OWNER
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Name | JAMES PATRICK WILSON
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Credential | DPM
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Telephone | 928-680-4934
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 213ES0103X
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Taxonomy Name | Foot & Ankle Surgery Podiatrist
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License Number | 0390
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License Number State | AZ
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