Provider Demographics
NPI:1275289712
Name:WILSON, PERCY LEE JR
Entity Type:Individual
Prefix:MR
First Name:PERCY
Middle Name:LEE
Last Name:WILSON
Suffix:JR
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 1:2289 WILSON AVE
Mailing Address - Street 2:
Mailing Address - City:PERRIS
Mailing Address - State:CA
Mailing Address - Zip Code:92571-3351
Mailing Address - Country:US
Mailing Address - Phone:951-490-8978
Mailing Address - Fax:
Practice Address - Street 1:2289 WILSON AVE
Practice Address - Street 2:
Practice Address - City:PERRIS
Practice Address - State:CA
Practice Address - Zip Code:92571-3351
Practice Address - Country:US
Practice Address - Phone:951-490-8978
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-23
Last Update Date:2022-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAN5842103172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver