Provider Demographics
NPI:1891785127
Name:WILSON, BONITA WESLEY (M D)
Entity Type:Individual
Prefix:
First Name:BONITA
Middle Name:WESLEY
Last Name:WILSON
Suffix:
Gender:F
Credentials:M D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2284
Mailing Address - Street 2:
Mailing Address - City:SKYLAND
Mailing Address - State:NC
Mailing Address - Zip Code:28776-2284
Mailing Address - Country:US
Mailing Address - Phone:828-575-2625
Mailing Address - Fax:828-350-2174
Practice Address - Street 1:511 PARK HILL DR
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22401-3377
Practice Address - Country:US
Practice Address - Phone:540-371-5660
Practice Address - Fax:540-372-6920
Is Sole Proprietor?:No
Enumeration Date:2005-10-27
Last Update Date:2017-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101038231207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA002784A38OtherMEDICARE PTAN
VA4053750OtherAETNA
VA561249571OtherVA HEALTH NETWORK
VA02-00285OtherUNITED HEALTHCARE
VA56124971OtherSENTARA
VA010061OtherVA PREMIER
VA229825OtherSOUTHERN HEALTH
VA3389897OtherAETNA
VAD17963OtherCIGNA
VAJ063-0002OtherCAREFIRST
VA010026610Medicaid
VA597372OtherALLIANCE/MAMSI
VA102827OtherBLUE CROSS
VA002784A38Medicare PIN
VA3389897OtherAETNA