Provider Demographics
NPI:1972602969
Name:WILSON, EDITH DIANE (MD)
Entity Type:Individual
Prefix:DR
First Name:EDITH
Middle Name:DIANE
Last Name:WILSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:615 LILLY RD NE STE 175
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98506-5179
Mailing Address - Country:US
Mailing Address - Phone:360-486-6772
Mailing Address - Fax:360-486-6775
Practice Address - Street 1:615 LILLY RD NE STE 175
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506-5179
Practice Address - Country:US
Practice Address - Phone:360-486-6772
Practice Address - Fax:360-486-6775
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2011-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY5500A208800000X
CO36402208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY110601500Medicaid
W9209OtherCLINIC MCAR #
W9208Medicare ID - Type Unspecified
W9209OtherCLINIC MCAR #