Provider Demographics
NPI:1104892967
Name:WILSON, CAROL K (CNM)
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:K
Last Name:WILSON
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:920 SOUTH OAK STREET
Mailing Address - Street 2:
Mailing Address - City:IOWA FALLS
Mailing Address - State:IA
Mailing Address - Zip Code:50126-9506
Mailing Address - Country:US
Mailing Address - Phone:641-648-7000
Mailing Address - Fax:641-648-7093
Practice Address - Street 1:920 SOUTH OAK STREET
Practice Address - Street 2:
Practice Address - City:IOWA FALLS
Practice Address - State:IA
Practice Address - Zip Code:50126-9506
Practice Address - Country:US
Practice Address - Phone:641-648-7000
Practice Address - Fax:641-648-7093
Is Sole Proprietor?:No
Enumeration Date:2006-02-23
Last Update Date:2014-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAB135725367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO87588820Medicaid
CO24581577Medicaid
COC810679Medicare PIN
COCO306343Medicare PIN
CO24581577Medicaid
CO87588820Medicaid
COP00441763Medicare PIN