Provider Demographics
NPI:1376766154
Name:WILSON, RAYMOND WESLEY (MD)
Entity Type:Individual
Prefix:DR
First Name:RAYMOND
Middle Name:WESLEY
Last Name:WILSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 7TH AVE
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99701-4949
Mailing Address - Country:US
Mailing Address - Phone:907-374-7944
Mailing Address - Fax:907-374-7941
Practice Address - Street 1:515 7TH AVE
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-4949
Practice Address - Country:US
Practice Address - Phone:907-374-7944
Practice Address - Fax:907-374-7941
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-10
Last Update Date:2024-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AKMEDS7087207RR0500X
AK5854207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK86811570844Medicaid
AKK163630OtherMEDICARE PTAN
MDC23608Medicare UPIN
AKK163630Medicare UPIN
AK86811570844Medicaid
AK86811570844Medicaid
MD9902RWOtherCAREFIRST BCBS