Basic Information
| Provider Information | |||||||||
| NPI: | 1003298571 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | EVAN | ||||||||
| MiddleName: | JONATHAN | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | IDC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1617 E REILLY ST | ||||||||
| Address2: | APT C | ||||||||
| City: | YUMA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853655659 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3104087127 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2989 EAST AROW ST | ||||||||
| Address2: | |||||||||
| City: | YUMA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85365 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3104087127 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2015 | ||||||||
| LastUpdateDate: | 09/16/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1710I1002X | Y | Other Service Providers | Military Health Care Provider | Independent Duty Corpsman |
ID Information
| ID | Type | State | Issuer | Description | 1124648471 | 01 | CA | US NAVY | OTHER |