Provider Demographics
NPI:1457395113
Name:WILSON, ROBERTA LYNN (CNP)
Entity Type:Individual
Prefix:
First Name:ROBERTA
Middle Name:LYNN
Last Name:WILSON
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:ROBERTA
Other - Middle Name:LYNN
Other - Last Name:ROGERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2000 W. 21ST ST
Mailing Address - Street 2:SUITE A-1
Mailing Address - City:CLOVIS
Mailing Address - State:NM
Mailing Address - Zip Code:88101
Mailing Address - Country:US
Mailing Address - Phone:575-762-8055
Mailing Address - Fax:575-763-3351
Practice Address - Street 1:2000 W. 21ST ST
Practice Address - Street 2:SUITE A-1
Practice Address - City:CLOVIS
Practice Address - State:NM
Practice Address - Zip Code:88101
Practice Address - Country:US
Practice Address - Phone:575-762-8055
Practice Address - Fax:575-763-3351
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2008-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMR25845367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
I26483Medicare UPIN