Provider Demographics
NPI:1275928897
Name:WILSON, JILL MALLORY FADAL (MD)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:MALLORY FADAL
Last Name:WILSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JILL
Other - Middle Name:MALLORY
Other - Last Name:FADAL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2008 CARIBOU DR
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80525-4325
Mailing Address - Country:US
Mailing Address - Phone:970-484-4757
Mailing Address - Fax:970-484-4759
Practice Address - Street 1:1389 CENTER DR STE 200
Practice Address - Street 2:
Practice Address - City:PARK CITY
Practice Address - State:UT
Practice Address - Zip Code:84098-7660
Practice Address - Country:US
Practice Address - Phone:970-484-4757
Practice Address - Fax:970-484-4759
Is Sole Proprietor?:No
Enumeration Date:2015-03-31
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY15751A2085R0202X
CODR.00705792085R0202X
UT10964555-12052085R0202X
NE355612085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology