Provider Demographics
NPI:1336234277
Name:WILSON, CHRISTINE (PA-C)
Entity Type:Individual
Prefix:MS
First Name:CHRISTINE
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:402 N 4TH STREET
Mailing Address - Street 2:SUITE 202
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98901-0190
Mailing Address - Country:US
Mailing Address - Phone:509-248-3782
Mailing Address - Fax:503-588-0531
Practice Address - Street 1:3896 BEVERLY AVE. SE
Practice Address - Street 2:BLDG. J, STE. 40
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97305-1374
Practice Address - Country:US
Practice Address - Phone:503-588-0076
Practice Address - Fax:503-588-0531
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2011-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA01463363A00000X
CAPA15054363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORPA01463OtherMEDICAL LICENSE OREGON
ORPA01463OtherMEDICAL LICENSE OREGON
CAOPA15040Medicare ID - Type UnspecifiedMEDICARE NUMBER