Provider Demographics
NPI:1003298571
Name:WILSON, EVAN JONATHAN (IDC)
Entity Type:Individual
Prefix:MR
First Name:EVAN
Middle Name:JONATHAN
Last Name:WILSON
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1617 E REILLY ST
Mailing Address - Street 2:APT C
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85365-5659
Mailing Address - Country:US
Mailing Address - Phone:310-408-7127
Mailing Address - Fax:
Practice Address - Street 1:2989 EAST AROW ST
Practice Address - Street 2:
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85365
Practice Address - Country:US
Practice Address - Phone:310-408-7127
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-22
Last Update Date:2015-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1124648471OtherUS NAVY