Basic Information
| Provider Information | |||||||||
| NPI: | 1932116985 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | CARLA | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | MD, PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 UNIVERSITY OF NEW MEXICO | ||||||||
| Address2: | MSC08 4640 | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871310001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059388465 | ||||||||
| FaxNumber: | 5059388414 | ||||||||
| Practice Location | |||||||||
| Address1: | 1001 WOODWARD PLACE NE | ||||||||
| Address2: | TRICORE REFERENCE LABORATORIES | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871020001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059388465 | ||||||||
| FaxNumber: | 5059388414 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/02/2006 | ||||||||
| LastUpdateDate: | 06/05/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0105X | 93-182 | NM | Y | Allopathic & Osteopathic Physicians | Pathology | Clinical Pathology/Laboratory Medicine |
No ID Information.