Provider Demographics
NPI:1770722589
Name:WILSON, KAREN R (MS)
Entity type:Individual
Prefix:
First Name:KAREN
Middle Name:R
Last Name:WILSON
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 17583
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92177-7583
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:707 BROADWAY
Practice Address - Street 2:2ND FLOOR
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101-5391
Practice Address - Country:US
Practice Address - Phone:858-410-1067
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-18
Last Update Date:2009-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA92-0180335171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator