Provider Demographics
NPI:1407874548
Name:WILSON, SHARON J (ARNP)
Entity Type:Individual
Prefix:
First Name:SHARON
Middle Name:J
Last Name:WILSON
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:SHARON
Other - Middle Name:J
Other - Last Name:CUSTARD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 3360
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3360
Mailing Address - Country:US
Mailing Address - Phone:866-366-2983
Mailing Address - Fax:
Practice Address - Street 1:930 N BROADWAY
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201-1585
Practice Address - Country:US
Practice Address - Phone:425-317-0300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2015-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN00151982163W00000X
WAAP30006683363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA42918UOtherREGENCE BLUESHIELD
WA0195595OtherLABOR & INDUSTRY
WA9643073Medicaid
WAG8877635Medicare PIN
WAS53762Medicare UPIN
WA42918UOtherREGENCE BLUESHIELD
WA8853870Medicare PIN