Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207QS0010X | Family Doctor - Sports Medicine | 92-377 | NM |
NPI | 1154309698 |
---|---|
Provider Name | Robert H Wilson |
First Address | Albuquerque, NM 87106-4917 |
Second Address | Albuquerque, NM 87106-4917 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 05/01/2006 |
Last Update Date | 10/01/2013 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
000E6907 | (05) | NM |
F34443 | (02) |