Individual
GWEN WILSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PA
Contact information
Practice address
2111 COLLEGE DR, REHOBOTH MCKINLEY CHRISTIAN HEALTH CARE SERVICES, GALLUP, NM 87301-5600
(505) 863-1820
Mailing address
1901 REDROCK DR, PFS DEPT, GALLUP, NM 87301-5683
(505) 863-7000
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
88-PA-01
NM
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
00093518
—
NM
01
—
10002165
LOVELACE HEALTH/SALUD
NM
05
—
326240
—
AZ
01
—
PROVP16800
MOLINA
—
Enumeration date
02/06/2006
Last updated
07/09/2007
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