Provider Demographics
NPI:1508824467
Name:BERNALES, WILSON FULLA (MD)
Entity Type:Individual
Prefix:DR
First Name:WILSON
Middle Name:FULLA
Last Name:BERNALES
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 1:428 S DURBIN ST STE 104
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82601-2818
Mailing Address - Country:US
Mailing Address - Phone:307-337-4284
Mailing Address - Fax:307-462-0922
Practice Address - Street 1:428 S DURBIN ST
Practice Address - Street 2:SUITE 104
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82601-2818
Practice Address - Country:US
Practice Address - Phone:307-337-4284
Practice Address - Fax:307-462-0922
Is Sole Proprietor?:No
Enumeration Date:2006-05-02
Last Update Date:2016-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC1-0007844207QA0505X
WY7632A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WYW22441Medicare PIN
WYW22434Medicare PIN