Provider Demographics
NPI:1558416107
Name:WILMOT, STEPHEN BRUCE (PT009355)
Entity Type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:BRUCE
Last Name:WILMOT
Suffix:
Gender:M
Credentials:PT009355
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5905 MURRAY PL
Mailing Address - Street 2:
Mailing Address - City:FAIR OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:95628-2510
Mailing Address - Country:US
Mailing Address - Phone:916-967-2308
Mailing Address - Fax:916-482-7798
Practice Address - Street 1:5740 WINDMILL WAY
Practice Address - Street 2:SUITE 15
Practice Address - City:CARMICHAEL
Practice Address - State:CA
Practice Address - Zip Code:95608-1379
Practice Address - Country:US
Practice Address - Phone:916-482-7698
Practice Address - Fax:916-482-7798
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT009355174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist