Provider Demographics
NPI:1891085262
Name:WILSON, STELLA ELIZABETH (MT)
Entity Type:Individual
Prefix:MS
First Name:STELLA
Middle Name:ELIZABETH
Last Name:WILSON
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 STONE LAKE ROAD
Mailing Address - Street 2:
Mailing Address - City:DULCE
Mailing Address - State:NM
Mailing Address - Zip Code:87528
Mailing Address - Country:US
Mailing Address - Phone:575-759-7309
Mailing Address - Fax:575-759-7294
Practice Address - Street 1:500 STONE LAKE ROAD
Practice Address - Street 2:
Practice Address - City:DULCE
Practice Address - State:NM
Practice Address - Zip Code:87528
Practice Address - Country:US
Practice Address - Phone:575-759-7309
Practice Address - Fax:575-759-7294
Is Sole Proprietor?:No
Enumeration Date:2011-04-19
Last Update Date:2012-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLTN 26432246QM0706X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246QM0706XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, PathologyMedical Technologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMHSZ196OtherMEDICARE PART B
NMK3526Medicaid
NMHSZ196OtherMEDICARE PART B