Basic Information
| Provider Information | |||||||||
| NPI: | 1184615650 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | SEAN | ||||||||
| MiddleName: | PATRICK | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 878 | ||||||||
| Address2: | |||||||||
| City: | SPRINGERVILLE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 859380878 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9283335333 | ||||||||
| FaxNumber: | 9283335100 | ||||||||
| Practice Location | |||||||||
| Address1: | 606 N MAIN ST | ||||||||
| Address2: | |||||||||
| City: | EAGAR | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 859259813 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9283335333 | ||||||||
| FaxNumber: | 9283335100 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2005 | ||||||||
| LastUpdateDate: | 11/21/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 32794 | AZ | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 880808 | 05 | AZ | MEDICAID |