| Doctor Name: | DR. DEIDRE A WILSON |
| NPI Number: | 1760634471 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | D.O. |
| License Number: | 4042 |
| Business Practice Address: | 8705 N Central Ave Ste B Phoenix, AZ - 850203119 |
| Business Phone Number: | 1877219578 |
| Business Fax Number: | 1877219578 |
| Mailing Address: | 111 E Dunlap Ave # 310, PHOENIX |
| State: | AZ |
| Postal Code: | 850202807 |
| Phone Number: | 6023055100 |
| Fax Number: | 8772195782 |
| NPI Enumeration Date: | 10/14/2008 |
| NPI Last Update Date: | 04/23/2012 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 208D00000X |
| License Number: | 4042 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | AZ |
| Taxonomy Type: | Allopathic & Osteopathic Physicians |
| Taxonomy Classification: | General Practice |
| Taxonomy Specialization: | |
| Taxonomy Definition: | |