Provider Demographics
NPI:1467635508
Name:WILSON, SHARON
Entity Type:Individual
Prefix:
First Name:SHARON
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4150 V ST
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95817-1460
Mailing Address - Country:US
Mailing Address - Phone:916-734-8583
Mailing Address - Fax:
Practice Address - Street 1:4150 V ST
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95817-1460
Practice Address - Country:US
Practice Address - Phone:916-734-8583
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-12
Last Update Date:2008-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
302R00000X
CAG57949207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No302R00000XManaged Care OrganizationsHealth Maintenance Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G579490Medicaid
CA00G579490Medicare PIN