Provider Demographics
NPI:1740764661
Name:WILSON, CORTNEY SERENE (SA-C)
Entity Type:Individual
Prefix:
First Name:CORTNEY
Middle Name:SERENE
Last Name:WILSON
Suffix:
Gender:F
Credentials:SA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1405 W SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT AYR
Mailing Address - State:IA
Mailing Address - Zip Code:50854-1267
Mailing Address - Country:US
Mailing Address - Phone:641-234-0657
Mailing Address - Fax:
Practice Address - Street 1:417 S EAST ST
Practice Address - Street 2:
Practice Address - City:CORYDON
Practice Address - State:IA
Practice Address - Zip Code:50060-1860
Practice Address - Country:US
Practice Address - Phone:641-872-2260
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-17
Last Update Date:2018-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA18-332246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical AssistantGroup - Single Specialty