Provider Demographics
NPI:1235519984
Name:WILSON, BRADLEY CRAIG
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:CRAIG
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 1:2807 MONTCLAIR AVE
Mailing Address - Street 2:
Mailing Address - City:PASCAGOULA
Mailing Address - State:MS
Mailing Address - Zip Code:39567-5287
Mailing Address - Country:US
Mailing Address - Phone:910-382-5414
Mailing Address - Fax:
Practice Address - Street 1:2807 MONTCLAIR AVE
Practice Address - Street 2:
Practice Address - City:PASCAGOULA
Practice Address - State:MS
Practice Address - Zip Code:39567-5287
Practice Address - Country:US
Practice Address - Phone:910-382-5414
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-08
Last Update Date:2015-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman