Provider Demographics
NPI:1538557210
Name:WILSON, DAVID NATHANIEL
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:NATHANIEL
Last Name:WILSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:269 S CANDY LN
Mailing Address - Street 2:
Mailing Address - City:COTTONWOOD
Mailing Address - State:AZ
Mailing Address - Zip Code:86326-4158
Mailing Address - Country:US
Mailing Address - Phone:928-634-2251
Mailing Address - Fax:
Practice Address - Street 1:269 S CANDY LN
Practice Address - Street 2:
Practice Address - City:COTTONWOOD
Practice Address - State:AZ
Practice Address - Zip Code:86326-4158
Practice Address - Country:US
Practice Address - Phone:928-634-2251
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-02
Last Update Date:2019-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ007929207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine