Provider Demographics
NPI:1811984248
Name:WILSON, SUZANNE M (DPM)
Entity type:Individual
Prefix:
First Name:SUZANNE
Middle Name:M
Last Name:WILSON
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:14212 AMBAUM BLVD SW
Mailing Address - Street 2:#103
Mailing Address - City:BURIEN
Mailing Address - State:WA
Mailing Address - Zip Code:98166-1449
Mailing Address - Country:US
Mailing Address - Phone:206-242-6553
Mailing Address - Fax:206-246-0468
Practice Address - Street 1:1609 116TH AVE NE
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004
Practice Address - Country:US
Practice Address - Phone:425-283-5093
Practice Address - Fax:425-283-5093
Is Sole Proprietor?:No
Enumeration Date:2005-09-30
Last Update Date:2017-03-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WAPO00000472213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1098623Medicaid
217000654Medicare ID - Type Unspecified
WA1098623Medicaid