Basic Information
| Provider Information | |||||||||
| NPI: | 1336234277 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | CHRISTINE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | P.A.-C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 402 N 4TH STREET | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | YAKIMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 989010190 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5092483782 | ||||||||
| FaxNumber: | 5035880531 | ||||||||
| Practice Location | |||||||||
| Address1: | 3896 BEVERLY AVE. SE | ||||||||
| Address2: | BLDG. J, STE. 40 | ||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973051374 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5035880076 | ||||||||
| FaxNumber: | 5035880531 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2006 | ||||||||
| LastUpdateDate: | 11/29/2011 | ||||||||
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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 | 363A00000X | PA01463 | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | PA15054 | CA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | PA01463 | 01 | OR | MEDICAL LICENSE OREGON | OTHER |