Provider Demographics
NPI:1043479330
Name:WILSON, E JOAN (CLS)
Entity type:Individual
Prefix:MS
First Name:E
Middle Name:JOAN
Last Name:WILSON
Suffix:
Gender:F
Credentials:CLS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1403
Mailing Address - Street 2:
Mailing Address - City:OCEAN PARK
Mailing Address - State:WA
Mailing Address - Zip Code:98640
Mailing Address - Country:US
Mailing Address - Phone:360-665-4599
Mailing Address - Fax:
Practice Address - Street 1:12000 STONE LAKE ROAD
Practice Address - Street 2:
Practice Address - City:DULCE
Practice Address - State:NM
Practice Address - Zip Code:87528
Practice Address - Country:US
Practice Address - Phone:505-759-7238
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-03
Last Update Date:2008-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS9905528246ZI1000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZI1000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherIllustration, Medical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM000K3526Medicaid
NMHSZ196OtherMEDICARE PART B
NM320057Medicare Oscar/Certification