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General NPI Number Information
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NPI Number | 1477517563
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Entity Type | Individual
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Provider Name | REGINALD WENDELL WILSON M.D.
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Gender | Male
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Dates
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Enumeration Date | 04/14/2006
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Last Update Date | 05/11/2017
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Provider Practice Location Address
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Address Line | 19505 52ND AVE W SUITE A
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City | LYNNWOOD
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State | WA
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Zip | 98036-5409
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Country | US
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Telephone | 206-623-3814
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Fax | 206-623-4327
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Provider Business Mailing Address
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Address Line | 19505 52ND AVE W SUITE A
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City | LYNNWOOD
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State | WA
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Zip | 98036-5409
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Country | US
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Telephone | 206-623-3814
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Fax | 206-623-4327
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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 | 207ZP0102X
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Taxonomy Name | Anatomic Pathology & Clinical Pathology Physician
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License Number | 030927
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License Number State | GA
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Taxonomy #2
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Taxonomy Code | 207ZP0102X
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Taxonomy Name | Anatomic Pathology & Clinical Pathology Physician
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License Number | MD 60318390
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License Number State | WA
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