Provider Demographics
NPI:1083960991
Name:WILSON, LAURA (DC)
Entity Type:Individual
Prefix:DR
First Name:LAURA
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1250 PINE ST
Mailing Address - Street 2:STE. 108
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94596-3685
Mailing Address - Country:US
Mailing Address - Phone:925-289-8011
Mailing Address - Fax:
Practice Address - Street 1:1250 PINE ST
Practice Address - Street 2:STE. 108
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94596-3685
Practice Address - Country:US
Practice Address - Phone:925-289-8011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-29
Last Update Date:2012-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA32124111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor