Provider Demographics
NPI:1306840947
Name:WILSON, JOSEPH NATHAN (MD)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:NATHAN
Last Name:WILSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 UTICA AVE
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79416-3111
Mailing Address - Country:US
Mailing Address - Phone:806-797-4985
Mailing Address - Fax:806-792-8588
Practice Address - Street 1:301 UTICA AVE
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79416-3111
Practice Address - Country:US
Practice Address - Phone:806-797-4985
Practice Address - Fax:806-792-8588
Is Sole Proprietor?:No
Enumeration Date:2005-06-10
Last Update Date:2022-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH7849174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX126414505Medicaid
TXE71024Medicare UPIN
TX86V302Medicare ID - Type Unspecified