Basic Information
| Provider Information | |||||||||
| NPI: | 1891273595 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | CASSANDRA | ||||||||
| MiddleName: | JANE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 367 N DINNER BELL DR | ||||||||
| Address2: | |||||||||
| City: | CALHAN | ||||||||
| State: | CO | ||||||||
| PostalCode: | 808088738 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7209359733 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 7150 CAMPUS DR STE 160 | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809203178 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195385600 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2018 | ||||||||
| LastUpdateDate: | 08/03/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | RBT-18-62187 | CO | Y | 193400000X SINGLE SPECIALTY GROUP |
No ID Information.