Provider Demographics
NPI:1003809765
Name:WILSON, LISHA LYNNE (MD)
Entity Type:Individual
Prefix:
First Name:LISHA
Middle Name:LYNNE
Last Name:WILSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 29TH ST
Mailing Address - Street 2:STE 501
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94609-3550
Mailing Address - Country:US
Mailing Address - Phone:510-268-1800
Mailing Address - Fax:510-268-1803
Practice Address - Street 1:400 29TH ST
Practice Address - Street 2:STE 501
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-3550
Practice Address - Country:US
Practice Address - Phone:510-268-1800
Practice Address - Fax:510-268-1803
Is Sole Proprietor?:No
Enumeration Date:2005-08-29
Last Update Date:2016-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG73584207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G00492Medicare UPIN