Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208D00000X | General Practice Physician | 30699 | MN |
NPI | 1033358924 |
---|---|
Provider Name | Richard Robert Wilson |
First Address | Arden Hills, MN 55112-5783 |
Second Address | Arden Hills, MN 55112-5783 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 17/02/2009 |
Last Update Date | 17/02/2009 |