Basic Information
| Provider Information | |||||||||
| NPI: | 1679567085 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2478 13TH ST SE | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973022546 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033622481 | ||||||||
| FaxNumber: | 5033717803 | ||||||||
| Practice Location | |||||||||
| Address1: | 2478 13TH ST SE | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973022546 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033622481 | ||||||||
| FaxNumber: | 5033717803 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2005 | ||||||||
| LastUpdateDate: | 04/23/2008 | ||||||||
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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 | 208000000X | MD121816 | OR | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | MD12816 | OR | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 241166 | 05 | OR | MEDICAID |