Basic Information
| Provider Information | |||||||||
| NPI: | 1063402840 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | GOLDER | ||||||||
| MiddleName: | N. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5865 | ||||||||
| Address2: | |||||||||
| City: | LUBBOCK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 794085865 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8067432898 | ||||||||
| FaxNumber: | 8067432787 | ||||||||
| Practice Location | |||||||||
| Address1: | 3601 4TH ST | ||||||||
| Address2: | MS 9406 | ||||||||
| City: | LUBBOCK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 794300002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8067437337 | ||||||||
| FaxNumber: | 8067437329 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2005 | ||||||||
| LastUpdateDate: | 11/10/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | H5095 | TX | N | Allopathic & Osteopathic Physicians | Pediatrics | 207SG0201X | H5095 | TX | Y | Allopathic & Osteopathic Physicians | Medical Genetics | Clinical Genetics (M.D.) |
ID Information
| ID | Type | State | Issuer | Description | 119194212 | 05 | TX | MEDICAID | 127048101 | 01 | TX | FIRSTCARE COMMERCIAL | OTHER | 119194205 | 05 | TX | MEDICAID | 8H8760 | 01 | TX | BC/BS | OTHER | 119194204 | 05 | TX | MEDICAID | 119194211 | 05 | TX | MEDICAID | 127048102 | 05 | TX | MEDICAID | 87286Z | 01 | TX | HMO BLUE | OTHER | Y0069496 | 01 | TX | DPS | OTHER | A562 | 01 | NM | TRIWEST | OTHER | 82994 | 01 | NM | PRESBYTERIAN COMMERCIAL | OTHER | 82994 | 05 | NM | MEDICAID | 100056830 A | 05 | OK | MEDICAID | 119194216 | 05 | TX | MEDICAID | 31405762 | 05 | NM | MEDICAID | AW6518914 | 01 | TX | DEA | OTHER |