| Doctor Name: | WANDA GAYLE WILSON |
| NPI Number: | 1033182118 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | DO |
| License Number: | R8779 |
| Business Practice Address: | 3559 Amazonas St Jefferson City, MO - 65109 |
| Business Phone Number: | 5738937848 |
| Business Fax Number: | 5738931984 |
| Mailing Address: | 3559 Amazonas St, Health Branch West JEFFERSON CITY |
| State: | MO |
| Postal Code: | 65109 |
| Phone Number: | 5738937848 |
| Fax Number: | 5738931984 |
| NPI Enumeration Date: | 02/09/2006 |
| NPI Last Update Date: | 06/30/2009 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 208D00000X |
| License Number: | R8779 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | MO |
| Taxonomy Type: | Allopathic & Osteopathic Physicians |
| Taxonomy Classification: | General Practice |
| Taxonomy Specialization: | |
| Taxonomy Definition: | |