Provider Demographics
NPI:1215464268
Name:WILSON, ANDREW (DO)
Entity type:Individual
Prefix:MR
First Name:ANDREW
Middle Name:
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:PO BOX 3570
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84110-3570
Mailing Address - Country:US
Mailing Address - Phone:801-727-2056
Mailing Address - Fax:303-780-0787
Practice Address - Street 1:3741 W 12600 S
Practice Address - Street 2:
Practice Address - City:RIVERTON
Practice Address - State:UT
Practice Address - Zip Code:84065-7215
Practice Address - Country:US
Practice Address - Phone:801-727-2056
Practice Address - Fax:770-701-6676
Is Sole Proprietor?:No
Enumeration Date:2017-05-20
Last Update Date:2022-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0065653207L00000X
390200000X
UT12994458-1204207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program