Provider Demographics
NPI:1326744624
Name:WILSON, SIDNEY L
Entity Type:Individual
Prefix:
First Name:SIDNEY
Middle Name:L
Last Name:WILSON
Suffix:
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 1:1223 WOOD CREEK TRL
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30076-4356
Mailing Address - Country:US
Mailing Address - Phone:404-915-2380
Mailing Address - Fax:
Practice Address - Street 1:1223 WOOD CREEK TRL
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-4356
Practice Address - Country:US
Practice Address - Phone:517-242-7433
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-07
Last Update Date:2023-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZE0600XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherElectroneurodiagnostic