Glenn Wilson, IDMT

Primary specialty

Independent Duty Medical TechniciansTaxonomy code 1710I1003X

Practice address

280 David L Goldfein St BLDG 23
Holloman Afb, NM 88330-8273

Phone

(707) 424-5107

NPI assigned

Jan 28, 2014

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1390867200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1711670400000",
    "number": "1720401789",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "228 SEABURY ST",
            "city": "SUISUN CITY",
            "state": "CA",
            "postal_code": "945854107"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "280 DAVID L GOLDFEIN ST BLDG 23",
            "city": "HOLLOMAN AFB",
            "state": "NM",
            "postal_code": "883308273",
            "telephone_number": "707-424-5107"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WILSON",
        "first_name": "GLENN",
        "credential": "IDMT",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2014-01-28",
        "last_updated": "2024-03-29",
        "certification_date": "2024-03-29",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1710I1003X",
            "taxonomy_group": "",
            "desc": "Military Health Care Provider, Independent Duty Medical Technicians",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Eric Matthew Ward, DO
• Felicia Imogen Webb
• Priscilla Webb, CADC
• Victoria Welch
• Jonathon Michael Williams
• Michael Winsten, D.O.
• Kevin Soon Leng Yeo, DO
• Derandoria Ann Young, MSW

• Independent Duty Medical Technicians in Holloman Afb, NM
• Providers in Holloman Afb, NM by specialty
• Independent Duty Medical Technicians in New Mexico

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 29, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.