Provider Demographics
NPI:1699396424
Name:WILBUR, JOHN LEE JR
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:LEE
Last Name:WILBUR
Suffix:JR
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 1:331 SIJEN AVE
Mailing Address - Street 2:
Mailing Address - City:WHITEMAN AFB
Mailing Address - State:MO
Mailing Address - Zip Code:65305-1269
Mailing Address - Country:US
Mailing Address - Phone:660-687-4341
Mailing Address - Fax:
Practice Address - Street 1:509TH MEDICAL GROUP
Practice Address - Street 2:
Practice Address - City:WHITEMAN AIR FORCE BASE
Practice Address - State:MO
Practice Address - Zip Code:64093
Practice Address - Country:US
Practice Address - Phone:660-687-4341
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-04
Last Update Date:2023-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY50149363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health