Provider Demographics
NPI:1760631592
Name:WILSON, THERESA
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:WILSON
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:PO BOX 35380
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89133-5380
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:724 S EL CAMINO REAL
Practice Address - Street 2:
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92672-4250
Practice Address - Country:US
Practice Address - Phone:949-493-6113
Practice Address - Fax:949-493-5851
Is Sole Proprietor?:No
Enumeration Date:2008-09-17
Last Update Date:2025-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8242363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily