MEDICARE: WANDA GAYLE WILSON DO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208D00000X	General Practice Physician	R8779	MO

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	P00200365	OTHER		RR MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	9183317004	OTHER	CIGNA
3	185418	OTHER	BCBS
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
5	829180	OTHER	FIRST HEALTH
6	D41738	OTHER	MERCY
7	251463	OTHER	HEALTHLINK

General Provider Information

NPI Number	:	1033182118
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WANDA GAYLE WILSON DO

Provider Business Mailing Address
First Line	:	3559 AMAZONAS ST
Second Line	:	HEALTH BRANCH WEST
City	:	JEFFERSON CITY
State	:	MO
Zip	:	65109
Country	:	US
Telephone Number	:	573-893-7848
Fax Number	:	573-893-1984

Provider Business Practice Location Address
First Line	:	3559 AMAZONAS ST
Second Line	:
City	:	JEFFERSON CITY
State	:	MO
Zip	:	65109
Country	:	US
Telephone Number	:	573-893-7848
Fax Number	:	573-893-1984

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/09/2006
Last Update Date	:	06/30/2009

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