Provider Demographics
NPI:1316391774
Name:WILSON, VASHON (MHS)
Entity Type:Individual
Prefix:
First Name:VASHON
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:MHS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11616 SOUTHFORK AVE STE 203
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70816-5241
Mailing Address - Country:US
Mailing Address - Phone:225-291-9646
Mailing Address - Fax:225-291-9692
Practice Address - Street 1:11616 SOUTHFORK AVE STE 203
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70816-5241
Practice Address - Country:US
Practice Address - Phone:225-291-9646
Practice Address - Fax:225-291-9692
Is Sole Proprietor?:No
Enumeration Date:2016-04-21
Last Update Date:2019-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA600751961Medicaid