Provider Demographics
NPI:1972985299
Name:WILSON, BRYAN RICHARD (MD)
Entity Type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:RICHARD
Last Name:WILSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 OSTRUM ST
Mailing Address - Street 2:
Mailing Address - City:BETHLEHEM
Mailing Address - State:PA
Mailing Address - Zip Code:18015-1000
Mailing Address - Country:US
Mailing Address - Phone:484-526-4903
Mailing Address - Fax:
Practice Address - Street 1:801 OSTRUM ST
Practice Address - Street 2:
Practice Address - City:BETHLEHEM
Practice Address - State:PA
Practice Address - Zip Code:18015
Practice Address - Country:US
Practice Address - Phone:484-526-4903
Practice Address - Fax:484-526-2153
Is Sole Proprietor?:No
Enumeration Date:2015-06-23
Last Update Date:2021-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV30830207PE0004X
PAMD461810207P00000X
PAMT209074207P00000X
NJ25MA10245300207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services