Provider Demographics
NPI:1003034018
Name:WILSON-CELESTINE, LYSTRA B (MD)
Entity type:Individual
Prefix:
First Name:LYSTRA
Middle Name:B
Last Name:WILSON-CELESTINE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:3400 DATA DR
Mailing Address - Street 2:ATTN: CREDENTIALING/PAYER ENROLLMENT
Mailing Address - City:RANCHO CORDOVA
Mailing Address - State:CA
Mailing Address - Zip Code:95670-7956
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:280 SIERRA COLLEGE DR STE 115
Practice Address - Street 2:
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945
Practice Address - Country:US
Practice Address - Phone:530-477-3119
Practice Address - Fax:530-274-2077
Is Sole Proprietor?:No
Enumeration Date:2007-04-23
Last Update Date:2018-05-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WAMD00048034207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology