Basic Information
Provider Information
NPI: 1003291147
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: WILSON
FirstName: LINDSEY
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
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OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 1115 SE 164TH AVE DEPT 358
Address2:  
City: VANCOUVER
State: WA
PostalCode: 986838004
CountryCode: US
TelephoneNumber: 3607291253
FaxNumber: 3607293185
Practice Location
Address1: 3377 RIVERBEND DR
Address2:  
City: SPRINGFIELD
State: OR
PostalCode: 974778803
CountryCode: US
TelephoneNumber: 5412226565
FaxNumber: 5412226567
Other Information
ProviderEnumerationDate: 07/29/2015
LastUpdateDate: 03/28/2018
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
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AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
363L00000X201707978NP-PPORY Physician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner 
363LF0000X9296007FLN Physician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily

No ID Information.


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