Basic Information
| Provider Information | |||||||||
| NPI: | 1194772525 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | SONE-SEERE | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 263 RAVENNA DR | ||||||||
| Address2: | |||||||||
| City: | LONG BEACH | ||||||||
| State: | CA | ||||||||
| PostalCode: | 908033613 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5627540703 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1115 S SUNSET AVE | ||||||||
| Address2: | |||||||||
| City: | WEST COVINA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917903940 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6268142434 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/30/2006 | ||||||||
| LastUpdateDate: | 05/01/2009 | ||||||||
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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 | 207P00000X | G59162 | CA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00G519620 | 05 | CA | MEDICAID |