Basic Information
| Provider Information | |||||||||
| NPI: | 1285638999 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | GLEN | ||||||||
| MiddleName: | P | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4901 LANG AVE NE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871094495 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5058428171 | ||||||||
| FaxNumber: | 5058573877 | ||||||||
| Practice Location | |||||||||
| Address1: | 4901 LANG AVE NE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871094495 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5058428171 | ||||||||
| FaxNumber: | 5058573877 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2005 | ||||||||
| LastUpdateDate: | 01/18/2017 | ||||||||
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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 | 2085R0202X | 2000-314 | NM | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 2258272 | 01 | NM | MEDICARE GROUP | OTHER | 52713 | 05 | NM | MEDICAID | 45138 | 05 | NM | MEDICAID | 600521002 | 01 | NM | MEDICARE IDTF | OTHER | 700521102 | 01 | NM | MEDICARE GROUP | OTHER | L0634 | 05 | NM | MEDICAID | 800521126 | 01 | NM | MEDICARE IDTF | OTHER | 66463 | 05 | NM | MEDICAID |