Provider Demographics
NPI:1396009676
Name:WILSON, JOHN A II
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:A
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 1:6054 GIANT FOREST LN
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89031-1663
Mailing Address - Country:US
Mailing Address - Phone:702-249-7122
Mailing Address - Fax:
Practice Address - Street 1:6054 GIANT FOREST LN
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89031-1663
Practice Address - Country:US
Practice Address - Phone:702-249-7122
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-01
Last Update Date:2012-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation PractitionerGroup - Single Specialty