Provider Demographics
NPI:1720417496
Name:WILSON, JOHN (LSA)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:WILSON
Suffix:
Gender:M
Credentials:LSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3905 MELCER DR STE 601
Mailing Address - Street 2:
Mailing Address - City:ROWLETT
Mailing Address - State:TX
Mailing Address - Zip Code:75088-4033
Mailing Address - Country:US
Mailing Address - Phone:214-227-2457
Mailing Address - Fax:214-764-0888
Practice Address - Street 1:3905 MELCER DR STE 601
Practice Address - Street 2:
Practice Address - City:ROWLETT
Practice Address - State:TX
Practice Address - Zip Code:75088-4033
Practice Address - Country:US
Practice Address - Phone:214-227-2457
Practice Address - Fax:214-764-0888
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-04
Last Update Date:2023-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXSA00753246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant