Basic Information
| Provider Information | |||||||||
| NPI: | 1679598080 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | MASON | ||||||||
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| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | WILSON | ||||||||
| OtherFirstName: | JAMES | ||||||||
| OtherMiddleName: | M | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | JR. | ||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3124 S 19TH ST | ||||||||
| Address2: | STE 140 | ||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984052433 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2534596510 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3124 S 19TH ST | ||||||||
| Address2: | STE 140 | ||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984052433 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2534596510 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2006 | ||||||||
| LastUpdateDate: | 08/11/2011 | ||||||||
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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 | 207R00000X | MD00018468 | WA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.