Basic Information
| Provider Information | |||||||||
| NPI: | 1104892967 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | CAROL | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | CNM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 920 SOUTH OAK STREET | ||||||||
| Address2: | |||||||||
| City: | IOWA FALLS | ||||||||
| State: | IA | ||||||||
| PostalCode: | 501269506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6416487000 | ||||||||
| FaxNumber: | 6416487093 | ||||||||
| Practice Location | |||||||||
| Address1: | 920 SOUTH OAK STREET | ||||||||
| Address2: | |||||||||
| City: | IOWA FALLS | ||||||||
| State: | IA | ||||||||
| PostalCode: | 501269506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6416487000 | ||||||||
| FaxNumber: | 6416487093 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/23/2006 | ||||||||
| LastUpdateDate: | 05/07/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367A00000X | B135725 | IA | Y | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |
ID Information
| ID | Type | State | Issuer | Description | 87588820 | 05 | CO | MEDICAID | 24581577 | 05 | CO | MEDICAID |