Provider Demographics
NPI:1518536580
Name:WILSON, KURTIS WAYNE (DO)
Entity Type:Individual
Prefix:
First Name:KURTIS
Middle Name:WAYNE
Last Name:WILSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2415 TRAVIS DR
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:IN
Mailing Address - Zip Code:46052-1266
Mailing Address - Country:US
Mailing Address - Phone:765-891-1202
Mailing Address - Fax:
Practice Address - Street 1:295 WHARTON LN NE
Practice Address - Street 2:
Practice Address - City:NORTON
Practice Address - State:VA
Practice Address - Zip Code:24273-1541
Practice Address - Country:US
Practice Address - Phone:276-679-7457
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-23
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN3810-03-0390OtherDRIVER'S LICENSE