Basic Information
| Provider Information | |||||||||
| NPI: | 1093886178 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | CHRISTOPHER | ||||||||
| MiddleName: | P | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5127 | ||||||||
| Address2: | |||||||||
| City: | EVERETT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982065127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4253395453 | ||||||||
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| Practice Location | |||||||||
| Address1: | 15418 MAIN ST UNIT 303A | ||||||||
| Address2: | |||||||||
| City: | MILL CREEK | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980129031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4253395453 | ||||||||
| FaxNumber: | 4252258028 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/12/2006 | ||||||||
| LastUpdateDate: | 10/30/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | MD00042104 | WA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 1035137 | 05 | WA | MEDICAID |