Provider Demographics
NPI:1578140349
Name:WILSON, TODD PATRICK
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:PATRICK
Last Name:WILSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1480 SEWARD AVE
Mailing Address - Street 2:
Mailing Address - City:SITKA
Mailing Address - State:AK
Mailing Address - Zip Code:99835-9454
Mailing Address - Country:US
Mailing Address - Phone:907-966-5473
Mailing Address - Fax:
Practice Address - Street 1:1480 SEWARD AVE
Practice Address - Street 2:
Practice Address - City:SITKA
Practice Address - State:AK
Practice Address - Zip Code:99835-9454
Practice Address - Country:US
Practice Address - Phone:907-966-5430
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-26
Last Update Date:2022-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman