Provider Demographics
NPI:1750023529
Name:WILSON, JONATHAN
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:WILSON
Suffix:
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 1:16905 SW 82ND CT
Mailing Address - Street 2:
Mailing Address - City:PALMETTO BAY
Mailing Address - State:FL
Mailing Address - Zip Code:33157-4705
Mailing Address - Country:US
Mailing Address - Phone:305-772-4178
Mailing Address - Fax:
Practice Address - Street 1:177 FORT WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-3733
Practice Address - Country:US
Practice Address - Phone:212-305-2500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-11
Last Update Date:2022-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program