Provider Demographics
NPI:1013076405
Name:WILSON, MARK R (QME, OMD, LAC)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:R
Last Name:WILSON
Suffix:
Gender:M
Credentials:QME, OMD, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11573 LOS OSOS VALLEY RD STE H
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93405-6497
Mailing Address - Country:US
Mailing Address - Phone:805-439-0044
Mailing Address - Fax:805-439-0779
Practice Address - Street 1:11573 LOS OSOS VALLEY RD STE H
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93405-6497
Practice Address - Country:US
Practice Address - Phone:805-439-0044
Practice Address - Fax:805-439-0779
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-08
Last Update Date:2023-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA005109171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist