Provider Demographics
NPI:1689440026
Name:WILSON, CASPER S
Entity Type:Individual
Prefix:
First Name:CASPER
Middle Name:S
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SARA
Other - Middle Name:ANN
Other - Last Name:MARTINEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1400 N JOHNSON AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:EL CAJON
Mailing Address - State:CA
Mailing Address - Zip Code:92020-1651
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2049 SKYLINE DR
Practice Address - Street 2:
Practice Address - City:LEMON GROVE
Practice Address - State:CA
Practice Address - Zip Code:91945-4221
Practice Address - Country:US
Practice Address - Phone:000-000-0000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-28
Last Update Date:2023-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA0000000000175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes175T00000XOther Service ProvidersPeer SpecialistGroup - Multi-Specialty