Provider Demographics
NPI:1235696675
Name:WILSON, SIDNEY EDWARD
Entity Type:Individual
Prefix:
First Name:SIDNEY
Middle Name:EDWARD
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 1:23170 MEADOW ST
Mailing Address - Street 2:
Mailing Address - City:CAPRON
Mailing Address - State:VA
Mailing Address - Zip Code:23829-2562
Mailing Address - Country:US
Mailing Address - Phone:757-651-3820
Mailing Address - Fax:
Practice Address - Street 1:23170 MEADOW ST
Practice Address - Street 2:
Practice Address - City:CAPRON
Practice Address - State:VA
Practice Address - Zip Code:23829-2562
Practice Address - Country:US
Practice Address - Phone:757-651-3820
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-21
Last Update Date:2019-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAT64705937172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver