Provider Demographics
NPI:1568641298
Name:WILSON, BARRY K (MD)
Entity Type:Individual
Prefix:MR
First Name:BARRY
Middle Name:K
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:PO BOX 7096
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95267-0096
Mailing Address - Country:US
Mailing Address - Phone:209-956-7725
Mailing Address - Fax:209-956-7733
Practice Address - Street 1:914 S SCHEUBER RD
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:WA
Practice Address - Zip Code:98531-9027
Practice Address - Country:US
Practice Address - Phone:360-736-2803
Practice Address - Fax:360-330-8642
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-30
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60207086207L00000X
ORMD191134207L00000X
WAMD 60207086207LP2900X
OH095930207LP2900X
PAMD436454207LP2900X
CA103336207LP2900X
CAA103336207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACA123104Medicare PIN
CACA167648Medicare PIN
CAP01339919Medicare PIN