Provider Demographics
NPI:1306199393
Name:WILSON, ELLIOT MAXWELL (CGC)
Entity Type:Individual
Prefix:
First Name:ELLIOT
Middle Name:MAXWELL
Last Name:WILSON
Suffix:
Gender:M
Credentials:CGC
Other - Prefix:
Other - First Name:MAX
Other - Middle Name:
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:700 S PARK ST
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53715-1830
Mailing Address - Country:US
Mailing Address - Phone:608-252-7458
Mailing Address - Fax:608-258-6772
Practice Address - Street 1:700 S PARK ST
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53715-1830
Practice Address - Country:US
Practice Address - Phone:608-252-7458
Practice Address - Fax:608-258-6772
Is Sole Proprietor?:No
Enumeration Date:2012-10-16
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes170300000XOther Service ProvidersGenetic Counselor, MS
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI61370OtherDEAN HEALTH INSURANCE