Provider Demographics
NPI:1548802028
Name:DR. ANNA WILSON DO PC
Entity Type:Organization
Organization Name:DR. ANNA WILSON DO PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANNA
Authorized Official - Middle Name:B
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:DO, PC
Authorized Official - Phone:530-273-2720
Mailing Address - Street 1:140 LITTON DR STE 208
Mailing Address - Street 2:
Mailing Address - City:GRASS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95945-5079
Mailing Address - Country:US
Mailing Address - Phone:530-273-2720
Mailing Address - Fax:
Practice Address - Street 1:140 LITTON DR STE 208
Practice Address - Street 2:
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945-5079
Practice Address - Country:US
Practice Address - Phone:530-273-2720
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:INSIGHT IMAGING
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-10-16
Last Update Date:2019-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1447561535Medicaid