Provider Demographics
NPI:1821850520
Name:NIU, WILSON
Entity Type:Individual
Prefix:
First Name:WILSON
Middle Name:
Last Name:NIU
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 1:1360 TOURNEY HILL LN
Mailing Address - Street 2:
Mailing Address - City:NIPOMO
Mailing Address - State:CA
Mailing Address - Zip Code:93444-9306
Mailing Address - Country:US
Mailing Address - Phone:626-321-8535
Mailing Address - Fax:
Practice Address - Street 1:1075 E BETTERAVIA RD
Practice Address - Street 2:
Practice Address - City:SANTA MARIA
Practice Address - State:CA
Practice Address - Zip Code:93454-7023
Practice Address - Country:US
Practice Address - Phone:805-621-7651
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-29
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program