Provider Demographics
NPI:1396078317
Name:WILSON, ROBERT MAX (MA)
Entity type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:MAX
Last Name:WILSON
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:618 MANZANO NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110
Mailing Address - Country:US
Mailing Address - Phone:505-220-9583
Mailing Address - Fax:505-925-4354
Practice Address - Street 1:618 MANZANO NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110
Practice Address - Country:US
Practice Address - Phone:505-220-9583
Practice Address - Fax:505-925-4354
Is Sole Proprietor?:No
Enumeration Date:2009-09-09
Last Update Date:2014-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
NM171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator