Provider Demographics
NPI:1659897536
Name:WILSON, MICHAEL
Entity Type:Individual
Prefix:
First Name:MICHAEL
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 1:428 CASCADE RD
Mailing Address - Street 2:
Mailing Address - City:CASCADE
Mailing Address - State:VA
Mailing Address - Zip Code:24069-3320
Mailing Address - Country:US
Mailing Address - Phone:434-548-7762
Mailing Address - Fax:
Practice Address - Street 1:1628 BUCKTOWN DR
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:VA
Practice Address - Zip Code:24543
Practice Address - Country:US
Practice Address - Phone:434-548-7762
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-22
Last Update Date:2017-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver