Provider Demographics
NPI:1679567788
Name:WILSON, GINA SIMONE (MD ( MEDICAL DOCTO)
Entity type:Individual
Prefix:DR
First Name:GINA
Middle Name:SIMONE
Last Name:WILSON
Suffix:
Gender:F
Credentials:MD ( MEDICAL DOCTO
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Mailing Address - Street 1:1115 SE 164TH AVE DEPT 358
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98683-8004
Mailing Address - Country:US
Mailing Address - Phone:541-902-1634
Mailing Address - Fax:541-902-9702
Practice Address - Street 1:340 9TH ST
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:OR
Practice Address - Zip Code:97439-9470
Practice Address - Country:US
Practice Address - Phone:541-902-1634
Practice Address - Fax:541-902-9702
Is Sole Proprietor?:No
Enumeration Date:2005-09-02
Last Update Date:2016-03-10
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
TN40235207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN40235OtherSTATE HEALTH LICENSE