Provider Demographics
NPI:1063825982
Name:DIZON, WILSON
Entity Type:Individual
Prefix:
First Name:WILSON
Middle Name:
Last Name:DIZON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6321 BUSHKILL CREEK CT
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89142-2818
Mailing Address - Country:US
Mailing Address - Phone:702-324-5099
Mailing Address - Fax:
Practice Address - Street 1:6321 BUSHKILL CREEK CT
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89142-2818
Practice Address - Country:US
Practice Address - Phone:702-324-5099
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-09
Last Update Date:2014-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV104100000XMedicaid