Provider Demographics
NPI:1922167345
Name:WILSON, JOE RANDALL (LPT)
Entity Type:Individual
Prefix:MR
First Name:JOE
Middle Name:RANDALL
Last Name:WILSON
Suffix:
Gender:M
Credentials:LPT
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2171 N FINE AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93727-1519
Mailing Address - Country:US
Mailing Address - Phone:559-455-2000
Mailing Address - Fax:559-455-2041
Practice Address - Street 1:2171 N FINE AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93727-1519
Practice Address - Country:US
Practice Address - Phone:559-455-2000
Practice Address - Fax:559-455-2041
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician