Provider Demographics
NPI:1124407978
Name:WILSON, BRIAN
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:WILSON
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 1:361 71ST AVE STE 104
Mailing Address - Street 2:
Mailing Address - City:GREELEY
Mailing Address - State:CO
Mailing Address - Zip Code:80634-9782
Mailing Address - Country:US
Mailing Address - Phone:970-515-5320
Mailing Address - Fax:970-515-5320
Practice Address - Street 1:361 71ST AVE STE 104
Practice Address - Street 2:
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80634-9782
Practice Address - Country:US
Practice Address - Phone:970-515-5025
Practice Address - Fax:970-515-5320
Is Sole Proprietor?:No
Enumeration Date:2015-05-27
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
No374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO079733108OtherDUNS