Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207RN0300X | Nephrologist | G44318 | CA |
NPI | 1033110465 |
---|---|
Provider Name | Dr. Carl Wilson |
First Address | Santa Rosa, CA 95405-4515 |
Second Address | Santa Rosa, CA 95405-4515 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 09/08/2005 |
Last Update Date | 25/07/2017 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
00G443180 | (05) | CA |
A92480 | (02) |