Provider Demographics
NPI:1306818125
Name:WILSON, TEICHA (MD)
Entity Type:Individual
Prefix:
First Name:TEICHA
Middle Name:
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 1:1901 REDROCK DR
Mailing Address - Street 2:PFS DEPT
Mailing Address - City:GALLUP
Mailing Address - State:NM
Mailing Address - Zip Code:87301-5683
Mailing Address - Country:US
Mailing Address - Phone:505-863-7000
Mailing Address - Fax:
Practice Address - Street 1:2111 COLLEGE DR
Practice Address - Street 2:REHOBOTH MCKINLEY CHRISTIAN HEALTH CARE SERVICES
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87301-5600
Practice Address - Country:US
Practice Address - Phone:505-863-1820
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-06
Last Update Date:2014-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2004-0819208000000X
WAMD600279152080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ953126Medicaid
NMNM009W12OtherBCBS
QMYPR0068268OtherMOLINA
NM202000082OtherPRESBYTERIAN HEALTH/SALUD
NM10019728OtherLOVELACE HEALTH/SALUD
NM42378516Medicaid
NM202000082OtherPRESBYTERIAN HEALTH/SALUD
348529002Medicare ID - Type Unspecified
348529003Medicare ID - Type Unspecified