Basic Information
| Provider Information | |||||||||
| NPI: | 1588685143 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | SHERRITA | ||||||||
| MiddleName: | COTTON | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 3509 FRENCH PARK DR | ||||||||
| Address2: | STE D | ||||||||
| City: | EDMOND | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730347296 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4057154500 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3509 FRENCH PARK DR | ||||||||
| Address2: | STE D | ||||||||
| City: | EDMOND | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730347296 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4057154500 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0101X | 19780 | OK | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology | 207ZP0101X | L1241 | TX | N | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology |
ID Information
| ID | Type | State | Issuer | Description | 100746640A | 05 | OK | MEDICAID | 731527740 | 01 | TAX ID/GROUP MEDICARE | OTHER |