Provider Demographics
NPI:1346566452
Name:WILSON, NATHAN RYAN (PLMHP)
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:RYAN
Last Name:WILSON
Suffix:
Gender:M
Credentials:PLMHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4732 S 131ST ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68137-1822
Mailing Address - Country:US
Mailing Address - Phone:402-697-3923
Mailing Address - Fax:402-697-3924
Practice Address - Street 1:4732 S 131ST ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68137-1822
Practice Address - Country:US
Practice Address - Phone:402-697-3923
Practice Address - Fax:402-697-3924
Is Sole Proprietor?:No
Enumeration Date:2010-04-14
Last Update Date:2010-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE9109101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47082303526Medicaid