Provider Demographics
NPI:1477517563
Name:WILSON, REGINALD WENDELL (MD)
Entity Type:Individual
Prefix:DR
First Name:REGINALD
Middle Name:WENDELL
Last Name:WILSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19505 52ND AVE W
Mailing Address - Street 2:SUITE A
Mailing Address - City:LYNNWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98036-5409
Mailing Address - Country:US
Mailing Address - Phone:206-623-3814
Mailing Address - Fax:206-623-4327
Practice Address - Street 1:19505 52ND AVE W
Practice Address - Street 2:SUITE A
Practice Address - City:LYNNWOOD
Practice Address - State:WA
Practice Address - Zip Code:98036-5409
Practice Address - Country:US
Practice Address - Phone:206-623-3814
Practice Address - Fax:206-623-4327
Is Sole Proprietor?:No
Enumeration Date:2006-04-14
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA030927207ZP0102X
WAMD 60318390207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000787652AMedicaid
GA10049819OtherAMERIGROUP
GAP00256641OtherRAILROAD MEDICARE
GA118365OtherPEACH STATE HLT PLANS
GA727301OtherBCBSGA PROVIDER #
GA297058OtherWELLCARE
GAG71173Medicare UPIN