Provider Demographics
NPI:1194229336
Name:WILSON, ANDREW STEPHEN (DO)
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:STEPHEN
Last Name:WILSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9040 JACKSON AVENUE
Mailing Address - Street 2:
Mailing Address - City:JOINT BASE LEWIS MCCHORD
Mailing Address - State:WA
Mailing Address - Zip Code:98431-0001
Mailing Address - Country:US
Mailing Address - Phone:253-968-1100
Mailing Address - Fax:253-968-0100
Practice Address - Street 1:9040 JACKSON AVENUE
Practice Address - Street 2:
Practice Address - City:JOINT BASE LEWIS MCCHORD
Practice Address - State:WA
Practice Address - Zip Code:98431-4504
Practice Address - Country:US
Practice Address - Phone:253-968-1100
Practice Address - Fax:253-968-0100
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-22
Last Update Date:2025-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102205803207R00000X, 207R00000X
TXU9389207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology