Provider Demographics
NPI:1508567090
Name:WILSON, MARYANNE
Entity Type:Individual
Prefix:
First Name:MARYANNE
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:PO BOX 1248
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94538-0124
Mailing Address - Country:US
Mailing Address - Phone:415-608-7081
Mailing Address - Fax:
Practice Address - Street 1:335 W SOUTH BOULDER RD STE 1
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:CO
Practice Address - Zip Code:80027-1192
Practice Address - Country:US
Practice Address - Phone:415-608-7081
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-13
Last Update Date:2023-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0018952208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation