Provider Demographics
NPI:1558745398
Name:WILSON, BRAVEN (DPH)
Entity Type:Individual
Prefix:
First Name:BRAVEN
Middle Name:
Last Name:WILSON
Suffix:
Gender:M
Credentials:DPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1440 S LEWIS AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74104-4624
Mailing Address - Country:US
Mailing Address - Phone:918-747-6429
Mailing Address - Fax:
Practice Address - Street 1:1440 S LEWIS AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74104-4624
Practice Address - Country:US
Practice Address - Phone:918-747-6429
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-10
Last Update Date:2015-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK15790183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist