Basic Information
| Provider Information | |||||||||
| NPI: | 1568641298 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | BARRY | ||||||||
| MiddleName: | K | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 7096 | ||||||||
| Address2: | |||||||||
| City: | STOCKTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 952670096 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2099567725 | ||||||||
| FaxNumber: | 2099567733 | ||||||||
| Practice Location | |||||||||
| Address1: | 914 S SCHEUBER RD | ||||||||
| Address2: | |||||||||
| City: | CENTRALIA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985319027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3607362803 | ||||||||
| FaxNumber: | 3603308642 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/30/2007 | ||||||||
| LastUpdateDate: | 04/29/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 04/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | MD60207086 | WA | N | Allopathic & Osteopathic Physicians | Anesthesiology | 207LP2900X | MD 60207086 | WA | N | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 207LP2900X | 095930 | OH | N | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 207LP2900X | MD436454 | PA | N | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 207LP2900X | 103336 | CA | N | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine | 207L00000X | A103336 | CA | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
No ID Information.