Provider Demographics
NPI:1851561682
Name:ROBERT HARRISON WILSON MD
Entity Type:Organization
Organization Name:ROBERT HARRISON WILSON MD
Other - Org Name:ROBERT H. WILSON, MD
Other - Org Type:Other Name
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:KABOOS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:253-564-4157
Mailing Address - Street 1:4401 BRIDGEPORT WAY W
Mailing Address - Street 2:
Mailing Address - City:UNIVERSITY PLACE
Mailing Address - State:WA
Mailing Address - Zip Code:98466-4201
Mailing Address - Country:US
Mailing Address - Phone:253-564-4157
Mailing Address - Fax:253-564-4813
Practice Address - Street 1:4401 BRIDGEPORT WAY W
Practice Address - Street 2:
Practice Address - City:UNIVERSITY PLACE
Practice Address - State:WA
Practice Address - Zip Code:98466-4201
Practice Address - Country:US
Practice Address - Phone:253-564-4157
Practice Address - Fax:253-564-4813
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-07
Last Update Date:2016-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00014627174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1214600Medicaid
WAGAB10084Medicare UPIN
WAGAB10083Medicare PIN