Provider Demographics
NPI:1447336680
Name:WILSON, EDWARD (DO)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:
Last Name:WILSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1955 COFFEEN AVE
Mailing Address - Street 2:
Mailing Address - City:SHERIDAN
Mailing Address - State:WY
Mailing Address - Zip Code:82801-5713
Mailing Address - Country:US
Mailing Address - Phone:307-672-0773
Mailing Address - Fax:307-672-2739
Practice Address - Street 1:1955 COFFEEN AVE
Practice Address - Street 2:
Practice Address - City:SHERIDAN
Practice Address - State:WY
Practice Address - Zip Code:82801-5713
Practice Address - Country:US
Practice Address - Phone:307-672-0773
Practice Address - Fax:307-672-2739
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-31
Last Update Date:2008-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY6604A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY119617100Medicaid
WY119617100Medicaid
W20417Medicare ID - Type Unspecified