Provider Demographics
NPI:1326031840
Name:WILSON, ANDREA (NP)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:ANDREA
Other - Middle Name:
Other - Last Name:KOZAK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:NP
Mailing Address - Street 1:9522 E SAN SALVADOR DR
Mailing Address - Street 2:STE 206
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85258-5557
Mailing Address - Country:US
Mailing Address - Phone:480-991-6624
Mailing Address - Fax:480-991-1649
Practice Address - Street 1:9522 E SAN SALVADOR DR
Practice Address - Street 2:STE 206
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85258-5557
Practice Address - Country:US
Practice Address - Phone:480-991-6624
Practice Address - Fax:480-991-1649
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN086815207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ643686Medicaid
AZ643686Medicaid
67674Medicare ID - Type Unspecified