Provider Demographics
NPI:1669033569
Name:WILSON, NOLAN LEE (OD)
Entity Type:Individual
Prefix:DR
First Name:NOLAN
Middle Name:LEE
Last Name:WILSON
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5015 BELMONT RD
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33647-1319
Mailing Address - Country:US
Mailing Address - Phone:813-787-5995
Mailing Address - Fax:
Practice Address - Street 1:655 BRANDON TOWN CENTER MALL
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-4770
Practice Address - Country:US
Practice Address - Phone:813-681-1036
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-23
Last Update Date:2019-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC5648152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist