Provider Demographics
NPI:1417278466
Name:WILSON, ALIYA L (MD)
Entity Type:Individual
Prefix:DR
First Name:ALIYA
Middle Name:L
Last Name:WILSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ALIYA
Other - Middle Name:IMAN
Other - Last Name:LAWS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 9007
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22906-9007
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1007 39TH AVE SE
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98374-2192
Practice Address - Country:US
Practice Address - Phone:253-435-3100
Practice Address - Fax:844-660-0690
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-14
Last Update Date:2022-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QP2300X
VA0101263744207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1417278466Medicaid