Active NPI
Gwen Wilson, PA
- Physician Assistant
- Gallup, NM
National Provider Identifier
1497727218
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Physician Assistant
- License
- 88-PA-01
- Practice address
- 2111 College Dr
Rehoboth McKinley Christian Health Care Services
Gallup, NM 87301-5600 - Phone
- (505) 863-1820
- NPI assigned
- Feb 6, 2006
- Sex
- Female
- Sole proprietor
- No
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 |
|---|---|---|---|---|
| Physician Assistant | 363A00000X | 88-PA-01 | NM | Primary |
Addresses
Primary practice location
2111 College Dr
Rehoboth McKinley Christian Health Care Services
Gallup, NM 87301-5600
Mailing address
1901 Redrock Dr
PFS Dept
Gallup, NM 87301-5683
Phone (505) 863-7000
Other identifiers 4
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 326240 | Medicaid | AZ | |
| 00093518 | Medicaid | NM | |
| 10002165 | Other | NM | LOVELACE HEALTH/SALUD |
| PROVP16800 | Other | MOLINA |
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
- Physician Assistant
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 88-PA-01 | NM | MD | Physician Assistant |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1139184000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1183939200000",
"number": "1497727218",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "1901 REDROCK DR",
"address_2": "PFS DEPT",
"city": "GALLUP",
"state": "NM",
"postal_code": "873015683",
"telephone_number": "505-863-7000"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "2111 COLLEGE DR",
"address_2": "REHOBOTH MCKINLEY CHRISTIAN HEALTH CARE SERVICES",
"city": "GALLUP",
"state": "NM",
"postal_code": "873015600",
"telephone_number": "505-863-1820"
}
],
"practiceLocations": [],
"basic": {
"last_name": "WILSON",
"first_name": "GWEN",
"credential": "PA",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2006-02-06",
"last_updated": "2007-07-09",
"status": "A"
},
"taxonomies": [
{
"code": "363A00000X",
"taxonomy_group": "",
"desc": "Physician Assistant",
"state": "NM",
"license": "88-PA-01",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "326240",
"state": "AZ"
},
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "00093518",
"state": "NM"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "LOVELACE HEALTH/SALUD",
"identifier": "10002165",
"state": "NM"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "MOLINA",
"identifier": "PROVP16800",
"state": null
}
],
"endpoints": [],
"other_names": []
}Other providers in Gallup, NM
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 9, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.