Provider Demographics
NPI:1669406799
Name:WILSON, GREGORY J (DO)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:J
Last Name:WILSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:208-381-2222
Mailing Address - Fax:
Practice Address - Street 1:2505 GREEN TECH DR STE C
Practice Address - Street 2:
Practice Address - City:STATE COLLEGE
Practice Address - State:PA
Practice Address - Zip Code:16803-2316
Practice Address - Country:US
Practice Address - Phone:814-235-0484
Practice Address - Fax:814-234-7587
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2023-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS-013257207R00000X
MO2010015957207R00000X
PAOS013257207RR0500X
IDO-0777207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1669406799Medicaid
PA101334728Medicaid
PA1013347280004Medicaid
ID20004855Medicare PIN
ID1669406799Medicaid