Active NPI
Robert Harrison Wilson, MD
- Family Medicine Physician
- University Place, WA
National Provider Identifier
1407858186
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Family Medicine Physician
- License
- MD00014627
- Practice address
- 4401 Bridgeport Way W
Suite 100
University Place, WA 98466-4201 - Phone
- (253) 564-4157
- Fax
- (253) 564-4813
- NPI assigned
- Aug 12, 2005
- Last updated
- Apr 24, 2014
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Family Medicine Physician | 207Q00000X | MD00014627 | WA | Primary |
Addresses
Primary practice location
4401 Bridgeport Way W
Suite 100
University Place, WA 98466-4201
Mailing address
4401 Bridgeport Way W
Suite 100
University Place, WA 98466-4201
Phone (253) 564-4157
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1214600 | Medicaid | WA |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Doctor of Medicine
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Laboratory Corporation of America | Past | Accepting new patients |
Organizations & group practices 1
Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.
-
- Clinical Medical Laboratory
- Walla Walla, WA
- NPI 1972485621
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1123804800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1398297600000",
"number": "1407858186",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "4401 BRIDGEPORT WAY W",
"address_2": "SUITE 100",
"city": "UNIVERSITY PLACE",
"state": "WA",
"postal_code": "984664201",
"telephone_number": "253-564-4157",
"fax_number": "253-564-4813"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "4401 BRIDGEPORT WAY W",
"address_2": "SUITE 100",
"city": "UNIVERSITY PLACE",
"state": "WA",
"postal_code": "984664201",
"telephone_number": "253-564-4157",
"fax_number": "253-564-4813"
}
],
"practiceLocations": [],
"basic": {
"last_name": "WILSON",
"first_name": "ROBERT",
"middle_name": "HARRISON",
"name_prefix": "Dr.",
"credential": "MD",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2005-08-12",
"last_updated": "2014-04-24",
"status": "A"
},
"taxonomies": [
{
"code": "207Q00000X",
"taxonomy_group": "",
"desc": "Family Medicine",
"state": "WA",
"license": "MD00014627",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "1214600",
"state": "WA"
}
],
"endpoints": [],
"other_names": []
}Other providers in University Place, WA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 24, 2014; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.