Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 213E00000X | Podiatrist | 3020 | TX |
Y | 222Z00000X | Podiatrist | 3020 | TX |
N | 213EP1101X | Primary Podiatric Medicine | DPM.200036 | LA |
N | 2081S0010X | Sports Medicine | DPM.200036 | LA |
N | 213ES0000X | Sports Medicine | DPM.200036 | LA |
N | 213ES0103X | Foot & Ankle Surgery | DPM.200036 | LA |
N | 213ES0131X | Foot Surgery | DPM.200036 | LA |
NPI | 1104970862 |
---|---|
Provider Name | Dr. Jon M Wilson JR. |
First Address | El Paso, TX 79907-4773 |
Second Address | El Paso, TX 79907-4773 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 22/01/2007 |
Last Update Date | 10/06/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
DPM.200036 | LA STATE LICENSE (01) | LA |