Provider Demographics
NPI:1477515690
Name:WILSON, KATHLEEN B (MD)
Entity Type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:B
Last Name:WILSON
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:1160 EAST 3900 SOUTH
Mailing Address - Street 2:SUITE 1200
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84124
Mailing Address - Country:US
Mailing Address - Phone:801-261-9651
Mailing Address - Fax:801-261-9656
Practice Address - Street 1:1160 E 3900 SOUTH
Practice Address - Street 2:SUITE 1200
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84124
Practice Address - Country:US
Practice Address - Phone:801-261-9651
Practice Address - Fax:801-261-9656
Is Sole Proprietor?:No
Enumeration Date:2006-04-04
Last Update Date:2010-01-14
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
UT5406394-1205207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
I03828Medicare UPIN