Provider Demographics
NPI:1437533858
Name:WILSON, HEATHER MARIE (DO)
Entity Type:Individual
Prefix:DR
First Name:HEATHER
Middle Name:MARIE
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 1:4695 SHORELINE DR
Mailing Address - Street 2:
Mailing Address - City:SPRING PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55384-9715
Mailing Address - Country:US
Mailing Address - Phone:952-442-7890
Mailing Address - Fax:
Practice Address - Street 1:4695 SHORELINE DR
Practice Address - Street 2:
Practice Address - City:SPRING PARK
Practice Address - State:MN
Practice Address - Zip Code:55384-9715
Practice Address - Country:US
Practice Address - Phone:952-442-7890
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-15
Last Update Date:2018-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015017160208D00000X
MN64602207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice