Individual
GLEN P WILSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
4901 LANG AVE NE, ALBUQUERQUE, NM 87109-4495
(505) 842-8171
(505) 857-3877
Mailing address
800 BRADBURY DR SE STE 116, ALBUQUERQUE, NM 87106-4310
(505) 272-1476
Taxonomy
Speciality
Code
Description
License number
State
2085R0202X
Diagnostic Radiology Physician
Primary
2000-314
NM
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
2258272
MEDICARE GROUP
NM
05
—
45138
—
NM
05
—
52713
—
NM
01
—
600521002
MEDICARE IDTF
NM
05
—
66463
—
NM
01
—
700521102
MEDICARE GROUP
NM
01
—
800521126
MEDICARE IDTF
NM
05
—
L0634
—
NM
Enumeration date
06/09/2005
Last updated
10/30/2024
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