Provider Demographics
NPI:1578727095
Name:WILSON, BRIAN
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:
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:PO BOX 1179
Mailing Address - Street 2:
Mailing Address - City:DALHART
Mailing Address - State:TX
Mailing Address - Zip Code:79022-1179
Mailing Address - Country:US
Mailing Address - Phone:806-244-2266
Mailing Address - Fax:806-244-7266
Practice Address - Street 1:116 ALABAMA ST
Practice Address - Street 2:
Practice Address - City:DALHART
Practice Address - State:TX
Practice Address - Zip Code:79022-5334
Practice Address - Country:US
Practice Address - Phone:806-244-2266
Practice Address - Fax:806-244-7266
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-14
Last Update Date:2008-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX0013033332B00000X
TX0029692332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1457780-01Medicaid
TX515744OtherBLUE CROSS BLUE SHILED
TX016110101Medicaid
TX0527130001Medicare NSC