Basic Information
Provider Information | |||||||||
NPI: | 1922159896 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WILSON | ||||||||
FirstName: | JOY | ||||||||
MiddleName: | DENISE | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 5015 S IH 35 | ||||||||
Address2: | SUITE 174 | ||||||||
City: | AUSTIN | ||||||||
State: | TX | ||||||||
PostalCode: | 787442713 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5128043202 | ||||||||
FaxNumber: | 5129019717 | ||||||||
Practice Location | |||||||||
Address1: | 5015 S IH 35 | ||||||||
Address2: | SUITE 174 | ||||||||
City: | AUSTIN | ||||||||
State: | TX | ||||||||
PostalCode: | 787442713 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5128043202 | ||||||||
FaxNumber: | 5129019717 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/16/2007 | ||||||||
LastUpdateDate: | 01/31/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/31/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 036143944 | IL | N |   | Allopathic & Osteopathic Physicians | Family Medicine |   | 207Q00000X | 62772 | MN | N |   | Allopathic & Osteopathic Physicians | Family Medicine |   | 207Q00000X | MD.36109 | AL | N |   | Allopathic & Osteopathic Physicians | Family Medicine |   | 207Q00000X | 2017023778 | MO | N |   | Allopathic & Osteopathic Physicians | Family Medicine |   | 207Q00000X | 67756-20 | WI | N |   | Allopathic & Osteopathic Physicians | Family Medicine |   | 207Q00000X | 10378410-1205 | UT | N |   | Allopathic & Osteopathic Physicians | Family Medicine |   | 207Q00000X | 04-40039 | KS | N |   | Allopathic & Osteopathic Physicians | Family Medicine |   | 207Q00000X | 30219 | NE | N |   | Allopathic & Osteopathic Physicians | Family Medicine |   | 207Q00000X | 32823 | OK | N |   | Allopathic & Osteopathic Physicians | Family Medicine |   | 207Q00000X | 25330 | MS | N |   | Allopathic & Osteopathic Physicians | Family Medicine |   | 207Q00000X | 10615 | SD | N |   | Allopathic & Osteopathic Physicians | Family Medicine |   | 207Q00000X | MD-44742 | IA | N |   | Allopathic & Osteopathic Physicians | Family Medicine |   | 207Q00000X | 14863 | ND | N |   | Allopathic & Osteopathic Physicians | Family Medicine |   | 207Q00000X | 312076 | LA | N |   | Allopathic & Osteopathic Physicians | Family Medicine |   | 207Q00000X | M5586 | TX | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
No ID Information.