Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111N00000X | Chiropractor | 4036 | AZ |
NPI | 1003954645 |
---|---|
Provider Name | Dr. Ron Clyde Wilson |
First Address | Mesa, AZ 85215-9793 |
Second Address | Mesa, AZ 85215 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 04/02/2007 |
Last Update Date | 11/07/2018 |