DR. REGINALD WENDELL WILSON M.D.
Complete NPI Record 1477517563
Pathology - Anatomic Pathology & Clinical Pathology in Lynnwood, WA
Active since April 14, 2006PECOS EnrolledAccepts Medicare Assignment
Complete NPI Dataset
This page contains the complete raw NPPES record for Dr. Reginald Wendell Wilson, M.D. (NPI 1477517563), an individual pathology provider in Lynnwood, WA. All 58 fields on file are listed with their current values and official NPPES definitions, exactly as recorded in the National Plan and Provider Enumeration System. Only fields that contain data are included, so the number of fields shown varies from one NPI record to another.
Use the tools below to filter fields by category, search within the record, or jump straight to a specific field. You can download the full record as a CSV, JSON, Markdown or text file, or filter first and export only the fields you need. The Print Clean Summary button produces a printer-friendly copy of the record.
Registry File Document Utilities
- NPI: 1477517563 Field 1/58
- The 10-position all-numeric identification number assigned by the NPS to uniquely identify a health care provider. The NPI number includes an ISO standard check-digit in the 10th position. There is no intelligence about the health care provider in the number.
- Entity Type Code: 1 Field 2/58
- Code describing the type of health care provider that is being assigned an NPI. Codes are 1 = (Person): individual human being who furnishes health care; 2 = (Non-person): entity other than an individual human being that furnishes health care (for example, hospital, SNF, hospital subunit, pharmacy, or HMO).
- Provider Last Name Legal Name: WILSON Field 3/58
- The last name of the provider. If the provider is an individual, this is the legal name.
- Provider First Name: REGINALD Field 4/58
- The first name of the provider, if the provider is an individual.
- Provider Middle Name: WENDELL Field 5/58
- The middle name of the provider, if the provider is an individual.
- Provider Name Prefix Text: DR. Field 6/58
- The name prefix or salutation of the provider if the provider is an individual; for example, Mr., Mrs., or Corporal.
- Provider Credential Text: M.D. Field 7/58
- The abbreviations for professional degrees or credentials used or held by the provider, if the provider is an individual. Examples are MD, DDS, CSW, CNA, AA, NP, RNA, or PSY. These credential designations will not be verified by NPS.
- Provider First Line Business Mailing Address: 19505 52ND AVE W Field 8/58
- The first line mailing address of the provider being identified. This data element may contain the same information as "Provider first line location address".
- Provider Second Line Business Mailing Address: SUITE A Field 9/58
- The second line mailing address of the provider being identified. This data element may contain the same information as "Provider second line location address".
- Provider Business Mailing Address City Name: LYNNWOOD Field 10/58
- The city name in the mailing address of the provider being identified.
- Provider Business Mailing Address State Name: WA Field 11/58
- The State or Province name in the mailing address of the provider being identified. This data element may contain the same information as "Provider location address State name".
- Provider Business Mailing Address Postal Code: 980365409 Field 12/58
- The postal ZIP or zone code in the mailing address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available. This data element may contain the same information as "Provider location address postal code".
- Provider Business Mailing Address Country Code If outside U S : US Field 13/58
- The country code in the mailing address of the provider being identified. This data element may contain the same information as "Provider location address country code".
- Provider Business Mailing Address Telephone Number: 2066233814 Field 14/58
- The telephone number associated with mailing address of the provider being identified. This data element may contain the same information as "Provider location address telephone number".
- Provider Business Mailing Address Fax Number: 2066234327 Field 15/58
- The fax number associated with the mailing address of the provider being identified. This data element may contain the same information as "Provider location address fax number".
- Provider First Line Business Practice Location Address: 19505 52ND AVE W Field 16/58
- The first line location address of the provider being identified. For providers with more than one physical location, this is the primary location. This address cannot include a Post Office box.
- Provider Second Line Business Practice Location Address: SUITE A Field 17/58
- The second line location address of the provider being identified. For providers with more than one physical location, this is the primary location. This address cannot include a Post Office box.
- Provider Business Practice Location Address City Name: LYNNWOOD Field 18/58
- The city name in the location address of the provider being identified.
- Provider Business Practice Location Address State Name: WA Field 19/58
- The State code in the location of the provider being identified.
- Provider Business Practice Location Address Postal Code: 980365409 Field 20/58
- The postal ZIP or zone code in the location address of the provider being identified. NOTE: ZIP code plus 4-digit extension, if available.
- Provider Business Practice Location Address Country Code If outside U S : US Field 21/58
- The country code in the location address of the provider being identified.
- Provider Business Practice Location Address Telephone Number: 2066233814 Field 22/58
- The telephone number associated with the location address of the provider being identified.
- Provider Business Practice Location Address Fax Number: 2066234327 Field 23/58
- The fax number associated with the location address of the provider being identified.
- Provider Gender Code: M Field 26/58
- The code designating the provider's gender if the provider is a person.
- Healthcare Provider Taxonomy Code 1: 207ZP0102X Field 27/58
- This field represents the provider's taxonomy code, which classifies their type, classification, and area of specialization. This code comes from the Healthcare Provider Taxonomy Code Set maintained by the National Uniform Claim Committee (NUCC). The NPS will associate these data with the license data for providers with Entity type code = 1.
- Provider License Number 1: MD 60318390 Field 28/58
- The license number issued to the provider being identified. The NPS can accommodate multiple license numbers for multiple specialties and for multiple States. The NPS will associate this data element with "provider taxonomy code".
- Provider License Number State Code 1: WA Field 29/58
- The two-letter state code representing the U.S. state or territory that issued the provider's license. This field is linked to the Provider License Number field and identifies the jurisdiction where that license is valid. A provider may have multiple state codes if they hold licenses in more than one state.
- Healthcare Provider Primary Taxonomy Switch 1: Y Field 30/58
- This field shows whether the related taxonomy code is the provider's primary specialty. It is a single-character value: "Y" indicates the taxonomy is the primary one, while "N" indicates it is not. Each provider record can have only one taxonomy code marked as primary.
- Healthcare Provider Taxonomy Code 2: 207ZP0102X Field 31/58
- This field represents the provider's taxonomy code, which classifies their type, classification, and area of specialization. This code comes from the Healthcare Provider Taxonomy Code Set maintained by the National Uniform Claim Committee (NUCC). The NPS will associate these data with the license data for providers with Entity type code = 1.
- Provider License Number 2: 030927 Field 32/58
- The license number issued to the provider being identified. The NPS can accommodate multiple license numbers for multiple specialties and for multiple States. The NPS will associate this data element with "provider taxonomy code".
- Provider License Number State Code 2: GA Field 33/58
- The two-letter state code representing the U.S. state or territory that issued the provider's license. This field is linked to the Provider License Number field and identifies the jurisdiction where that license is valid. A provider may have multiple state codes if they hold licenses in more than one state.
- Healthcare Provider Primary Taxonomy Switch 2: N Field 34/58
- This field shows whether the related taxonomy code is the provider's primary specialty. It is a single-character value: "Y" indicates the taxonomy is the primary one, while "N" indicates it is not. Each provider record can have only one taxonomy code marked as primary.
- Other Provider Identifier 1: 297058 Field 35/58
- An additional identifier number for the provider, either current or previously used. This may include IDs issued by health plans, state agencies, or other organizations. The value is collected from the NPI application or update form.
- Other Provider Identifier Type Code 1: 01 Field 36/58
- A code that specifies the type of additional identifier associated with the provider, either current or past. Examples include UPIN (Universal Provider Identification Number), NSC (National Supplier Clearinghouse), OSCAR (CMS Certification Number), DEA (Drug Enforcement Administration number), state Medicaid ID, or a plan-specific PIN. The value is collected from the NPI application or update form.
- Other Provider Identifier State 1: GA Field 37/58
- The two-letter state code representing the U.S. state or territory that issued the additional provider identifier. This links the Other Provider Identifier to the state where it is valid or was assigned.
- Other Provider Identifier Issuer 1: WELLCARE Field 38/58
- The name of the organization, agency, or health plan that assigned the additional provider identifier. This identifies who issued the number linked to Other Provider Identifier 1 (for example, a state Medicaid agency, Medicare, or a private insurance company).
- Other Provider Identifier 2: P00256641 Field 39/58
- An additional identifier number for the provider, either current or previously used. This may include IDs issued by health plans, state agencies, or other organizations. The value is collected from the NPI application or update form.
- Other Provider Identifier Type Code 2: 01 Field 40/58
- A code that specifies the type of additional identifier associated with the provider, either current or past. Examples include UPIN (Universal Provider Identification Number), NSC (National Supplier Clearinghouse), OSCAR (CMS Certification Number), DEA (Drug Enforcement Administration number), state Medicaid ID, or a plan-specific PIN. The value is collected from the NPI application or update form.
- Other Provider Identifier State 2: GA Field 41/58
- The two-letter state code representing the U.S. state or territory that issued the additional provider identifier. This links the Other Provider Identifier to the state where it is valid or was assigned.
- Other Provider Identifier Issuer 2: RAILROAD MEDICARE Field 42/58
- The name of the organization, agency, or health plan that assigned the additional provider identifier. This identifies who issued the number linked to Other Provider Identifier 1 (for example, a state Medicaid agency, Medicare, or a private insurance company).
- Other Provider Identifier 3: 118365 Field 43/58
- An additional identifier number for the provider, either current or previously used. This may include IDs issued by health plans, state agencies, or other organizations. The value is collected from the NPI application or update form.
- Other Provider Identifier Type Code 3: 01 Field 44/58
- A code that specifies the type of additional identifier associated with the provider, either current or past. Examples include UPIN (Universal Provider Identification Number), NSC (National Supplier Clearinghouse), OSCAR (CMS Certification Number), DEA (Drug Enforcement Administration number), state Medicaid ID, or a plan-specific PIN. The value is collected from the NPI application or update form.
- Other Provider Identifier State 3: GA Field 45/58
- The two-letter state code representing the U.S. state or territory that issued the additional provider identifier. This links the Other Provider Identifier to the state where it is valid or was assigned.
- Other Provider Identifier Issuer 3: PEACH STATE HLT PLANS Field 46/58
- The name of the organization, agency, or health plan that assigned the additional provider identifier. This identifies who issued the number linked to Other Provider Identifier 1 (for example, a state Medicaid agency, Medicare, or a private insurance company).
- Other Provider Identifier 4: 727301 Field 47/58
- An additional identifier number for the provider, either current or previously used. This may include IDs issued by health plans, state agencies, or other organizations. The value is collected from the NPI application or update form.
- Other Provider Identifier Type Code 4: 01 Field 48/58
- A code that specifies the type of additional identifier associated with the provider, either current or past. Examples include UPIN (Universal Provider Identification Number), NSC (National Supplier Clearinghouse), OSCAR (CMS Certification Number), DEA (Drug Enforcement Administration number), state Medicaid ID, or a plan-specific PIN. The value is collected from the NPI application or update form.
- Other Provider Identifier State 4: GA Field 49/58
- The two-letter state code representing the U.S. state or territory that issued the additional provider identifier. This links the Other Provider Identifier to the state where it is valid or was assigned.
- Other Provider Identifier Issuer 4: BCBSGA PROVIDER # Field 50/58
- The name of the organization, agency, or health plan that assigned the additional provider identifier. This identifies who issued the number linked to Other Provider Identifier 1 (for example, a state Medicaid agency, Medicare, or a private insurance company).
- Other Provider Identifier 5: 10049819 Field 51/58
- An additional identifier number for the provider, either current or previously used. This may include IDs issued by health plans, state agencies, or other organizations. The value is collected from the NPI application or update form.
- Other Provider Identifier Type Code 5: 01 Field 52/58
- A code that specifies the type of additional identifier associated with the provider, either current or past. Examples include UPIN (Universal Provider Identification Number), NSC (National Supplier Clearinghouse), OSCAR (CMS Certification Number), DEA (Drug Enforcement Administration number), state Medicaid ID, or a plan-specific PIN. The value is collected from the NPI application or update form.
- Other Provider Identifier State 5: GA Field 53/58
- The two-letter state code representing the U.S. state or territory that issued the additional provider identifier. This links the Other Provider Identifier to the state where it is valid or was assigned.
- Other Provider Identifier Issuer 5: AMERIGROUP Field 54/58
- The name of the organization, agency, or health plan that assigned the additional provider identifier. This identifies who issued the number linked to Other Provider Identifier 1 (for example, a state Medicaid agency, Medicare, or a private insurance company).
- Other Provider Identifier 6: 000787652A Field 55/58
- An additional identifier number for the provider, either current or previously used. This may include IDs issued by health plans, state agencies, or other organizations. The value is collected from the NPI application or update form.
- Other Provider Identifier Type Code 6: 05 Field 56/58
- A code that specifies the type of additional identifier associated with the provider, either current or past. Examples include UPIN (Universal Provider Identification Number), NSC (National Supplier Clearinghouse), OSCAR (CMS Certification Number), DEA (Drug Enforcement Administration number), state Medicaid ID, or a plan-specific PIN. The value is collected from the NPI application or update form.
- Other Provider Identifier State 6: GA Field 57/58
- The two-letter state code representing the U.S. state or territory that issued the additional provider identifier. This links the Other Provider Identifier to the state where it is valid or was assigned.
- Is Sole Proprietor: N Field 58/58
- Indicates whether the provider is registered as a sole proprietor. This is a single-character code: "Y" means the provider operates as a sole proprietor, and "N" means they do not.
Other Provider Identifiers 7
Legacy and payer-issued identifiers reported to the NPPES registry for this provider.
727301 Other
Identifier 1/7State: GA · Issuer: Bcbsga Provider #
Other: An additional provider identifier that does not correspond to any of the other defined identifier type categories.
Other: An additional provider identifier that does not correspond to any of the other defined identifier type categories.
118365 Other
Identifier 2/7State: GA · Issuer: Peach State Hlt Plans
Other: An additional provider identifier that does not correspond to any of the other defined identifier type categories.
Other: An additional provider identifier that does not correspond to any of the other defined identifier type categories.
P00256641 Other
Identifier 3/7State: GA · Issuer: Railroad Medicare
Other: An additional provider identifier that does not correspond to any of the other defined identifier type categories.
Other: An additional provider identifier that does not correspond to any of the other defined identifier type categories.
297058 Other
Identifier 4/7State: GA · Issuer: Wellcare
Other: An additional provider identifier that does not correspond to any of the other defined identifier type categories.
Other: An additional provider identifier that does not correspond to any of the other defined identifier type categories.
10049819 Other
Identifier 5/7State: GA · Issuer: Amerigroup
Other: An additional provider identifier that does not correspond to any of the other defined identifier type categories.
Other: An additional provider identifier that does not correspond to any of the other defined identifier type categories.
000787652A Medicaid
Identifier 6/7State: GA
Medicaid (State-specific): A provider identification number assigned by an individual state's Medicaid program, used for billing and enrollment within that state's Medicaid system.
Medicaid (State-specific): A provider identification number assigned by an individual state's Medicaid program, used for billing and enrollment within that state's Medicaid system.
G71173 Medicare UPIN
Identifier 7/7State: GA
Medicare UPIN (Unique Physician Identification Number): A legacy six-character alphanumeric identifier previously issued by Medicare to individual physicians before being retired and replaced by the NPI system.
Medicare UPIN (Unique Physician Identification Number): A legacy six-character alphanumeric identifier previously issued by Medicare to individual physicians before being retired and replaced by the NPI system.
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