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General NPI Number Information
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NPI Number | 1972602969
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Entity Type | Individual
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Provider Name | EDITH DIANE WILSON MD
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Gender | Female
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Dates
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Enumeration Date | 09/22/2006
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Last Update Date | 08/29/2011
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Provider Practice Location Address
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Address Line | 615 LILLY RD NE STE 175
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City | OLYMPIA
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State | WA
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Zip | 98506-5179
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Country | US
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Telephone | 360-486-6772
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Fax | 360-486-6775
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Provider Business Mailing Address
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Address Line | 615 LILLY RD NE STE 175
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City | OLYMPIA
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State | WA
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Zip | 98506-5179
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Country | US
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Telephone | 360-486-6772
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Fax | 360-486-6775
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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 | 208800000X
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Taxonomy Name | Urology Physician
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License Number | 5500A
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License Number State | WY
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Taxonomy #2
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Taxonomy Code | 208800000X
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Taxonomy Name | Urology Physician
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License Number | 36402
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License Number State | CO
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