Provider Demographics
NPI:1225557358
Name:WILSON, NATHAN PAUL
Entity Type:Individual
Prefix:MR
First Name:NATHAN
Middle Name:PAUL
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 1:1680 N FAIR OAKS AVE
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91103-1642
Mailing Address - Country:US
Mailing Address - Phone:626-798-7272
Mailing Address - Fax:
Practice Address - Street 1:333 S CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90013-1724
Practice Address - Country:US
Practice Address - Phone:213-625-5009
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-09
Last Update Date:2017-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)