Provider Demographics
NPI:1861854234
Name:CORDERO, WILSON (RN)
Entity Type:Individual
Prefix:
First Name:WILSON
Middle Name:
Last Name:CORDERO
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:PO BOX 10704
Mailing Address - Street 2:
Mailing Address - City:PONCE
Mailing Address - State:PR
Mailing Address - Zip Code:00732-0704
Mailing Address - Country:US
Mailing Address - Phone:939-265-5102
Mailing Address - Fax:
Practice Address - Street 1:184 CALLE GUADALUPE PISO 2
Practice Address - Street 2:INSPIRA PONCE
Practice Address - City:PONCE
Practice Address - State:PR
Practice Address - Zip Code:00730
Practice Address - Country:US
Practice Address - Phone:787-709-4130
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-24
Last Update Date:2016-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR56777P3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant