Provider Demographics
NPI:1407538598
Name:WILSON, MARCUS LEVON
Entity Type:Individual
Prefix:
First Name:MARCUS
Middle Name:LEVON
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 1:3218 E BELL RD # 2142
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85032-2727
Mailing Address - Country:US
Mailing Address - Phone:702-349-8118
Mailing Address - Fax:
Practice Address - Street 1:5800 W CHARLESTON BLVD APT 2029
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89146-1296
Practice Address - Country:US
Practice Address - Phone:702-349-8118
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-07
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker