Provider Demographics
NPI:1053810184
Name:WILSON, HEIDI KATHERINE
Entity type:Individual
Prefix:
First Name:HEIDI
Middle Name:KATHERINE
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 1:2035 HURLEY WAY STE 290
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95825-3221
Mailing Address - Country:US
Mailing Address - Phone:916-758-9730
Mailing Address - Fax:
Practice Address - Street 1:2035 HURLEY WAY STE 290
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95825-3221
Practice Address - Country:US
Practice Address - Phone:916-758-9730
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-05
Last Update Date:2019-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156F00000XEye and Vision Services ProvidersTechnician/Technologist