Provider Demographics
NPI:1285898809
Name:WILSON, JOHNETTE B III (RT)
Entity type:Individual
Prefix:
First Name:JOHNETTE
Middle Name:B
Last Name:WILSON
Suffix:III
Gender:F
Credentials:RT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2923 75TH AVE
Mailing Address - Street 2:PO BOX 5056
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94605-2903
Mailing Address - Country:US
Mailing Address - Phone:415-571-0542
Mailing Address - Fax:
Practice Address - Street 1:2923 75TH AVE
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94605-2903
Practice Address - Country:US
Practice Address - Phone:415-571-0542
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-13
Last Update Date:2008-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA44981247100000X
CA176908247100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247100000XTechnologists, Technicians & Other Technical Service ProvidersRadiologic Technologist