Provider Demographics
NPI:1356439590
Name:WILSON, MICHAEL BRITT (DC)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:BRITT
Last Name:WILSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1510 W YAKIMA AVE
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98902-2951
Mailing Address - Country:US
Mailing Address - Phone:509-453-5726
Mailing Address - Fax:509-453-7899
Practice Address - Street 1:1510 W YAKIMA AVE
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98902-2951
Practice Address - Country:US
Practice Address - Phone:509-453-5726
Practice Address - Fax:509-453-7899
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH00001425111N00000X
OR27 1449111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA16740OtherLABOR & INDUSTRIES
WA2052702Medicaid
WA16740OtherLABOR & INDUSTRIES
WA000119405Medicare ID - Type Unspecified