Individual
WANDA GAYLE WILSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
DO
Contact information
Practice address
3559 AMAZONAS ST, JEFFERSON CITY, MO 65109
(573) 893-7848
(573) 893-1984
Mailing address
3559 AMAZONAS ST, HEALTH BRANCH WEST, JEFFERSON CITY, MO 65109
(573) 893-7848
(573) 893-1984
Taxonomy
Speciality
Code
Description
License number
State
208D00000X
General Practice Physician
Primary
R8779
MO
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
185418
BCBS
—
05
—
241488329
—
MO
01
—
251463
HEALTHLINK
—
01
—
829180
FIRST HEALTH
—
01
—
9183317004
CIGNA
—
01
—
D41738
MERCY
—
01
—
P00200365
RR MEDICARE
—
Enumeration date
02/09/2006
Last updated
06/30/2009
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