Provider Demographics
NPI:1417147422
Name:WILSON, TESHINA NICOLE (DO)
Entity Type:Individual
Prefix:
First Name:TESHINA
Middle Name:NICOLE
Last Name:WILSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1465 65TH ST
Mailing Address - Street 2:#432
Mailing Address - City:EMERYVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:94608-1062
Mailing Address - Country:US
Mailing Address - Phone:510-285-6814
Mailing Address - Fax:
Practice Address - Street 1:1030 NEVIN AVE
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:CA
Practice Address - Zip Code:94801-3122
Practice Address - Country:US
Practice Address - Phone:510-215-5001
Practice Address - Fax:510-215-1115
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-26
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC20009495207Q00000X
CA13746207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine