Provider Demographics
NPI:1407858186
Name:WILSON, ROBERT HARRISON (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:HARRISON
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 1:4401 BRIDGEPORT WAY W
Mailing Address - Street 2:SUITE 100
Mailing Address - City:UNIVERSITY PLACE
Mailing Address - State:WA
Mailing Address - Zip Code:98466-4201
Mailing Address - Country:US
Mailing Address - Phone:253-564-4157
Mailing Address - Fax:253-564-4813
Practice Address - Street 1:4401 BRIDGEPORT WAY W
Practice Address - Street 2:SUITE 100
Practice Address - City:UNIVERSITY PLACE
Practice Address - State:WA
Practice Address - Zip Code:98466-4201
Practice Address - Country:US
Practice Address - Phone:253-564-4157
Practice Address - Fax:253-564-4813
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-12
Last Update Date:2014-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00014627207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1214600Medicaid
A08873Medicare UPIN
AB10084Medicare ID - Type Unspecified