Provider Demographics
NPI:1972649648
Name:WILSON, NANCY JANE (MD)
Entity Type:Individual
Prefix:
First Name:NANCY JANE
Middle Name:
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 1:930 HUALAPAI WAY
Mailing Address - Street 2:
Mailing Address - City:PEACH SPRINGS
Mailing Address - State:AZ
Mailing Address - Zip Code:86434
Mailing Address - Country:US
Mailing Address - Phone:928-769-1168
Mailing Address - Fax:
Practice Address - Street 1:943 HUALAPAI WAY
Practice Address - Street 2:
Practice Address - City:PEACH SPRINGS
Practice Address - State:AZ
Practice Address - Zip Code:86434
Practice Address - Country:US
Practice Address - Phone:928-769-2900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2012-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7218208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2088324Medicaid
OH2088324Medicaid