Provider Demographics
NPI:1396201216
Name:WILSON, ANTHONY L (CRM)
Entity Type:Individual
Prefix:MR
First Name:ANTHONY
Middle Name:L
Last Name:WILSON
Suffix:
Gender:M
Credentials:CRM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1942 SHERIDAN AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97459-3416
Mailing Address - Country:US
Mailing Address - Phone:541-256-4686
Mailing Address - Fax:541-756-2111
Practice Address - Street 1:155 S EMPIRE BLVD
Practice Address - Street 2:
Practice Address - City:COOS BAY
Practice Address - State:OR
Practice Address - Zip Code:97420-3374
Practice Address - Country:US
Practice Address - Phone:541-256-4686
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-15
Last Update Date:2020-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR19-CRM-044175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR19-CRM-044OtherMHACBO