Provider Demographics
NPI:1700383445
Name:WILSON, EARL ANDRE (RN)
Entity Type:Individual
Prefix:MR
First Name:EARL
Middle Name:ANDRE
Last Name:WILSON
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1157 NE 37TH PL
Mailing Address - Street 2:
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33033-5915
Mailing Address - Country:US
Mailing Address - Phone:786-223-0193
Mailing Address - Fax:
Practice Address - Street 1:1157 NE 37TH PL
Practice Address - Street 2:
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33033-5915
Practice Address - Country:US
Practice Address - Phone:786-223-0193
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-10
Last Update Date:2018-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9288865163WC0200X, 163WM0705X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine
No163WM0705XNursing Service ProvidersRegistered NurseMedical-SurgicalGroup - Single Specialty