Provider Demographics
NPI:1447256805
Name:TSO, WILBUR A (MD)
Entity type:Individual
Prefix:
First Name:WILBUR
Middle Name:A
Last Name:TSO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 N AUBURN AVE
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-8411
Mailing Address - Country:US
Mailing Address - Phone:505-327-9876
Mailing Address - Fax:505-326-6650
Practice Address - Street 1:211 N AUBURN AVE
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87401-8411
Practice Address - Country:US
Practice Address - Phone:505-327-9876
Practice Address - Fax:505-326-6650
Is Sole Proprietor?:No
Enumeration Date:2005-06-21
Last Update Date:2011-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM81-330207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM48182826Medicaid
NMC 98185Medicare UPIN
NM48182826Medicaid