Provider Demographics
NPI:1326511288
Name:WILSON, BURTON ROBERT II
Entity Type:Individual
Prefix:
First Name:BURTON
Middle Name:ROBERT
Last Name:WILSON
Suffix:II
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 1:1010 E DREXEL AVE
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78210-3131
Mailing Address - Country:US
Mailing Address - Phone:210-421-8585
Mailing Address - Fax:
Practice Address - Street 1:7330 SAN PEDRO AVE STE 800
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78216-6268
Practice Address - Country:US
Practice Address - Phone:210-875-9456
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-03
Last Update Date:2019-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX212679164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse