Provider Demographics
NPI:1528081015
Name:WILSON, DIANE LYN (MD)
Entity type:Individual
Prefix:DR
First Name:DIANE
Middle Name:LYN
Last Name:WILSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:570 ASBURY ST
Mailing Address - Street 2:SUITE 106B
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-1849
Mailing Address - Country:US
Mailing Address - Phone:612-802-4704
Mailing Address - Fax:
Practice Address - Street 1:570 ASBURY ST
Practice Address - Street 2:SUITE 106B
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-1849
Practice Address - Country:US
Practice Address - Phone:612-802-4704
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN236842084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN3568OtherHEALTHPARTNERS PIN
MN1011752OtherPREFERRED ONE PIN
MN29795WIOtherBC PROVIDER #
MN1011752OtherPREFERRED ONE PIN