Provider Demographics
NPI:1114917812
Name:WILSON, SEAN E (DPM)
Entity Type:Individual
Prefix:
First Name:SEAN
Middle Name:E
Last Name:WILSON
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:19475 W NORTH AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53045-4199
Mailing Address - Country:US
Mailing Address - Phone:262-780-4400
Mailing Address - Fax:262-780-4425
Practice Address - Street 1:2424 S 90TH ST
Practice Address - Street 2:SUITE 500
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53227-2455
Practice Address - Country:US
Practice Address - Phone:414-328-8600
Practice Address - Fax:414-328-8686
Is Sole Proprietor?:No
Enumeration Date:2005-10-24
Last Update Date:2020-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI780025213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43225100Medicaid
WI00090410Medicare ID - Type Unspecified
WIU72035Medicare UPIN
WI43225100Medicaid