Basic Information
| Provider Information | |||||||||
| NPI: | 1508824467 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BERNALES | ||||||||
| FirstName: | WILSON | ||||||||
| MiddleName: | FULLA | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 428 S DURBIN ST STE 104 | ||||||||
| Address2: | |||||||||
| City: | CASPER | ||||||||
| State: | WY | ||||||||
| PostalCode: | 826012818 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3073374284 | ||||||||
| FaxNumber: | 3074620922 | ||||||||
| Practice Location | |||||||||
| Address1: | 428 S DURBIN ST | ||||||||
| Address2: | SUITE 104 | ||||||||
| City: | CASPER | ||||||||
| State: | WY | ||||||||
| PostalCode: | 826012818 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3073374284 | ||||||||
| FaxNumber: | 3074620922 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2006 | ||||||||
| LastUpdateDate: | 12/08/2016 | ||||||||
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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 | 207QA0505X | C1-0007844 | DE | Y | Allopathic & Osteopathic Physicians | Family Medicine | Adult Medicine | 207Q00000X | 7632A | WY | N | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.