Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207PE0004X | Emergency Medical Services | MD60078036 | WA |
NPI | 1083877559 |
---|---|
Provider Name | Dr. Lisa Marie Wilson |
First Address | Philadelphia, PA 19128-3716 |
Second Address | Seattle, WA 98101 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 05/07/2008 |
Last Update Date | 11/05/2021 |