Provider Demographics
NPI:1316381460
Name:WILSON, SHELLY RENEE (MD, PHD)
Entity Type:Individual
Prefix:
First Name:SHELLY
Middle Name:RENEE
Last Name:WILSON
Suffix:
Gender:F
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 26666
Mailing Address - Street 2:PHS PROVIDER ENROLLMENT
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87125-6666
Mailing Address - Country:US
Mailing Address - Phone:505-923-6700
Mailing Address - Fax:
Practice Address - Street 1:201 CEDAR ST SE STE 820
Practice Address - Street 2:KIDNEY TRANSPLANT CENTER
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106-8710
Practice Address - Country:US
Practice Address - Phone:505-841-1434
Practice Address - Fax:505-222-2149
Is Sole Proprietor?:No
Enumeration Date:2013-04-19
Last Update Date:2020-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2020-1086204F00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204F00000XAllopathic & Osteopathic PhysiciansTransplant Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program