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General NPI Number Information
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NPI Number | 1639229040
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Entity Type | Individual
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Provider Name | LAWRENCE WOODROW WILSON MD
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Gender | Male
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Dates
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Enumeration Date | 01/11/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 5701 BALLOON FIESTA PARKWAY CARE OF BLUE CROSS BLUE SHIELD OF NEW MEXICO
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City | ALBUQUERQUE
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State | NM
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Zip | 87113
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Country | US
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Telephone | 505-816-2093
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Fax | 505-816-3608
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Provider Business Mailing Address
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Address Line | 5701 BALLOON FIESTA PARKWAY CARE OF BLUE CROSS BLUE SHIELD OF NEW MEXICO
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City | ALBUQUERQUE
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State | NM
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Zip | 87113
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Country | US
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Telephone | 505-816-2093
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Fax | 505-816-3608
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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 | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 99-332
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License Number State | NM
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Taxonomy #2
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 4269
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License Number State | ND
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