Provider Demographics
NPI:1720179716
Name:WILSON, CATHERINE J (DPM)
Entity Type:Individual
Prefix:DR
First Name:CATHERINE
Middle Name:J
Last Name:WILSON
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:2660 CRIMSON CANYON DR
Mailing Address - Street 2:SUITE 130
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89128-0845
Mailing Address - Country:US
Mailing Address - Phone:702-453-3799
Mailing Address - Fax:702-453-5741
Practice Address - Street 1:2660 CRIMSON CANYON DR
Practice Address - Street 2:SUITE 130
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-0845
Practice Address - Country:US
Practice Address - Phone:702-453-3799
Practice Address - Fax:702-453-5741
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2015-07-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NV0306213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100502770Medicaid
NVV38483Medicare PIN
NV100502770Medicaid