Provider Demographics
NPI:1467604744
Name:WILSON, KEITH C (LSA)
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:C
Last Name:WILSON
Suffix:
Gender:M
Credentials:LSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2503 ROBIN KNOLL CT
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:TX
Mailing Address - Zip Code:77545-8167
Mailing Address - Country:US
Mailing Address - Phone:281-509-2017
Mailing Address - Fax:
Practice Address - Street 1:2503 ROBIN KNOLL CT
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:TX
Practice Address - Zip Code:77545-8167
Practice Address - Country:US
Practice Address - Phone:281-509-2017
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-16
Last Update Date:2016-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXSA00410246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant