Basic Information
| Provider Information | |||||||||
| NPI: | 1134180094 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | HARRY | ||||||||
| MiddleName: | LEE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 440 RAYNOLDS ST | ||||||||
| Address2: | |||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 799051613 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9152154480 | ||||||||
| FaxNumber: | 9152155386 | ||||||||
| Practice Location | |||||||||
| Address1: | 2001 NORTH OREGON STREET | ||||||||
| Address2: | PATHOLOGY DEPT | ||||||||
| City: | EL PASO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 79902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9155776011 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/30/2006 | ||||||||
| LastUpdateDate: | 11/26/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | 94425 | NM | N | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology | 207ZP0102X | 22817 | CO | N | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology | 207ZP0213X | 22817 | CO | N | Allopathic & Osteopathic Physicians | Pathology | Pediatric Pathology | 207ZP0213X | 94425 | NM | N | Allopathic & Osteopathic Physicians | Pathology | Pediatric Pathology | 207ZP0213X | J5061 | TX | N | Allopathic & Osteopathic Physicians | Pathology | Pediatric Pathology | 2080P0207X | 22817 | CO | N | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Hematology-Oncology | 2080P0207X | 94425 | NM | N | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Hematology-Oncology | 2080P0207X | J5061 | TX | N | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Hematology-Oncology | 207ZP0102X | J5061 | TX | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | J5671 | 05 | NM | MEDICAID | 117414601 | 01 | TX | CIDC | OTHER | 117414603 | 05 | TX | MEDICAID |