Provider Demographics
NPI:1306225107
Name:WILSON, W. A JR
Entity Type:Individual
Prefix:MR
First Name:W.
Middle Name:A
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 1:511 CROWN ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11213-5126
Mailing Address - Country:US
Mailing Address - Phone:718-778-0985
Mailing Address - Fax:
Practice Address - Street 1:137 MONTAGUE ST # 365
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11201-3548
Practice Address - Country:US
Practice Address - Phone:718-245-4917
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-26
Last Update Date:2015-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY580982163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse