Provider Demographics
NPI:1073531687
Name:WILSON, MARY S (NP)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:S
Last Name:WILSON
Suffix:
Gender:F
Credentials:NP
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Mailing Address - Street 1:PO BOX 6065
Mailing Address - Street 2:
Mailing Address - City:OCEAN VIEW
Mailing Address - State:HI
Mailing Address - Zip Code:96737-6065
Mailing Address - Country:US
Mailing Address - Phone:808-939-8100
Mailing Address - Fax:
Practice Address - Street 1:92-8691 LOTUS BLOSSOM LANE 6&7
Practice Address - Street 2:92-8691 LOTUS BLOSSOM LANE 6&7
Practice Address - City:OCEAN VIEW
Practice Address - State:HI
Practice Address - Zip Code:96737-9673
Practice Address - Country:US
Practice Address - Phone:808-939-8100
Practice Address - Fax:808-829-3672
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2019-02-21
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
HIAPRN-1997363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1073531687Medicaid
VA10106478Medicaid
VA10106478Medicaid