Provider Demographics
NPI:1497054886
Name:WILTON, TINA LARAY
Entity type:Individual
Prefix:MRS
First Name:TINA
Middle Name:LARAY
Last Name:WILTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:957 INDUSTRIAL RD STE B
Mailing Address - Street 2:
Mailing Address - City:SAN CARLOS
Mailing Address - State:CA
Mailing Address - Zip Code:94070-4152
Mailing Address - Country:US
Mailing Address - Phone:415-265-7514
Mailing Address - Fax:
Practice Address - Street 1:957 INDUSTRIAL RD
Practice Address - Street 2:SUITE B
Practice Address - City:SAN CARLOS
Practice Address - State:CA
Practice Address - Zip Code:94070-4151
Practice Address - Country:US
Practice Address - Phone:415-265-7514
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-24
Last Update Date:2011-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker