Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208C00000X | Colorectal Surgeon | 31405 | OK |
NPI | 1316006083 |
---|---|
Provider Name | Dr. Matthew Ryan Wilson |
First Address | Tulsa, OK 74104-4419 |
Second Address | Tulsa, OK 74104-4419 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 08/12/2006 |
Last Update Date | 29/06/2016 |