Individual
WILSON REAL
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
RN, BSN
Contact information
Practice address
3550 N INTERSTATE AVE, PORTLAND, OR 97227
(503) 813-2000
Mailing address
3550 N INTERSTATE AVE, PORTLAND, OR 97227-1196
(971) 484-2356
Taxonomy
Speciality
Code
Description
License number
State
363LP0808X
Psychiatric/Mental Health Nurse Practitioner
Primary
10023691
OR
363LP0808X
Psychiatric/Mental Health Nurse Practitioner
AP61535948
WA
Other
Enumeration date
09/27/2022
Last updated
07/31/2024
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