Provider Demographics
NPI:1821468174
Name:WILSON, DEVIN GRAHAM (ND)
Entity Type:Individual
Prefix:DR
First Name:DEVIN
Middle Name:GRAHAM
Last Name:WILSON
Suffix:
Gender:M
Credentials:ND
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:78900 AVENUE 47
Mailing Address - Street 2:STE 102
Mailing Address - City:LA QUINTA
Mailing Address - State:CA
Mailing Address - Zip Code:92253-2070
Mailing Address - Country:US
Mailing Address - Phone:760-600-5325
Mailing Address - Fax:
Practice Address - Street 1:78900 AVENUE 47
Practice Address - Street 2:STE 102
Practice Address - City:LA QUINTA
Practice Address - State:CA
Practice Address - Zip Code:92253-2070
Practice Address - Country:US
Practice Address - Phone:760-600-5325
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-30
Last Update Date:2015-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3004175F00000X
CAND759175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175F00000XOther Service ProvidersNaturopath