Basic Information
| Provider Information | |||||||||
| NPI: | 1891785127 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | BONITA | ||||||||
| MiddleName: | WESLEY | ||||||||
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| Credential: | M. D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2284 | ||||||||
| Address2: | |||||||||
| City: | SKYLAND | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287762284 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8285752625 | ||||||||
| FaxNumber: | 8283502174 | ||||||||
| Practice Location | |||||||||
| Address1: | 511 PARK HILL DR | ||||||||
| Address2: | |||||||||
| City: | FREDERICKSBURG | ||||||||
| State: | VA | ||||||||
| PostalCode: | 224013377 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5403715660 | ||||||||
| FaxNumber: | 5403726920 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/27/2005 | ||||||||
| LastUpdateDate: | 04/07/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207K00000X | 0101038231 | VA | Y | Allopathic & Osteopathic Physicians | Allergy & Immunology |
ID Information
| ID | Type | State | Issuer | Description | 002784A38 | 01 | VA | MEDICARE PTAN | OTHER | 4053750 | 01 | VA | AETNA | OTHER | 561249571 | 01 | VA | VA HEALTH NETWORK | OTHER | 02-00285 | 01 | VA | UNITED HEALTHCARE | OTHER | 56124971 | 01 | VA | SENTARA | OTHER | 010061 | 01 | VA | VA PREMIER | OTHER | 229825 | 01 | VA | SOUTHERN HEALTH | OTHER | 3389897 | 01 | VA | AETNA | OTHER | D17963 | 01 | VA | CIGNA | OTHER | J063-0002 | 01 | VA | CAREFIRST | OTHER | 010026610 | 05 | VA | MEDICAID | 597372 | 01 | VA | ALLIANCE/MAMSI | OTHER | 102827 | 01 | VA | BLUE CROSS | OTHER |