Provider Demographics
NPI:1164456471
Name:WILSON, FREDERIC BARLOW I (MD)
Entity Type:Individual
Prefix:
First Name:FREDERIC
Middle Name:BARLOW
Last Name:WILSON
Suffix:I
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:80 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:COUPEVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:98239-9500
Mailing Address - Country:US
Mailing Address - Phone:360-678-4424
Mailing Address - Fax:360-678-5161
Practice Address - Street 1:80 N MAIN ST
Practice Address - Street 2:
Practice Address - City:COUPEVILLE
Practice Address - State:WA
Practice Address - Zip Code:98239-9500
Practice Address - Country:US
Practice Address - Phone:360-678-4424
Practice Address - Fax:360-678-5161
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2017-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00030372207X00000X, 207XS0114X, 207XX0801X
AZ44684207XX0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0801XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Trauma
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XS0114XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryAdult Reconstructive Orthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2049935Medicaid
WAG8873782Medicare PIN
AZZ146902Medicare PIN