Provider Demographics
NPI:1790794931
Name:WILSON, SHAWN H (DO)
Entity Type:Individual
Prefix:DR
First Name:SHAWN
Middle Name:H
Last Name:WILSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3916 STATE ST
Mailing Address - Street 2:#300
Mailing Address - City:SANTA BARBARA
Mailing Address - State:CA
Mailing Address - Zip Code:93105-5602
Mailing Address - Country:US
Mailing Address - Phone:800-230-5160
Mailing Address - Fax:805-564-5087
Practice Address - Street 1:110 S 9TH AVE
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98902-3315
Practice Address - Country:US
Practice Address - Phone:509-575-5061
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2010-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOP00002116207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA212148OtherLABOR & INDUSTRIES - YAKIMA LOCATION
WA8461048Medicaid
WAP00339532OtherRAILROAD MEDICARE
WA4141WIOtherBLUESHIELD - YAKIMA LOCATION
WA212148OtherLABOR & INDUSTRIES - YAKIMA LOCATION
I30600Medicare UPIN