Provider Demographics
NPI:1255776258
Name:WILSON, KEITH GARNETT
Entity type:Individual
Prefix:
First Name:KEITH
Middle Name:GARNETT
Last Name:WILSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:155 N FRESNO ST
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93701-2302
Mailing Address - Country:US
Mailing Address - Phone:559-499-6440
Mailing Address - Fax:559-499-6441
Practice Address - Street 1:155 N FRESNO ST
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93701
Practice Address - Country:US
Practice Address - Phone:559-499-6440
Practice Address - Fax:559-499-6441
Is Sole Proprietor?:No
Enumeration Date:2013-05-03
Last Update Date:2018-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA132622207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine