Provider Demographics
NPI:1922694488
Name:WILSON, LEONARD W
Entity Type:Individual
Prefix:MR
First Name:LEONARD
Middle Name:W
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 1:456 E BROWN ST APT 206
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53212-3846
Mailing Address - Country:US
Mailing Address - Phone:414-736-8708
Mailing Address - Fax:
Practice Address - Street 1:456 E BROWN ST APT 206
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53212-3846
Practice Address - Country:US
Practice Address - Phone:414-736-8708
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-17
Last Update Date:2020-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist