Provider Demographics
NPI:1144726670
Name:WILSON, MARTHA JO (FNP-C)
Entity type:Individual
Prefix:
First Name:MARTHA
Middle Name:JO
Last Name:WILSON
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:MARTY
Other - Middle Name:J
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:4140 CENTENNIAL HILLS BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82609-3265
Mailing Address - Country:US
Mailing Address - Phone:307-265-7205
Mailing Address - Fax:307-235-6262
Practice Address - Street 1:4140 CENTENNIAL HILLS BLVD STE A
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82609-3265
Practice Address - Country:US
Practice Address - Phone:307-265-7205
Practice Address - Fax:307-235-6262
Is Sole Proprietor?:No
Enumeration Date:2018-04-03
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY1741363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily