Provider Demographics
NPI:1629792239
Name:REAL, WILSON (RN, BSN)
Entity type:Individual
Prefix:
First Name:WILSON
Middle Name:
Last Name:REAL
Suffix:
Gender:M
Credentials:RN, BSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3550 N INTERSTATE AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97227-1196
Mailing Address - Country:US
Mailing Address - Phone:971-484-2356
Mailing Address - Fax:
Practice Address - Street 1:3550 N INTERSTATE AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97227
Practice Address - Country:US
Practice Address - Phone:503-813-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-27
Last Update Date:2024-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10023691363LP0808X
WAAP61535948363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health