Provider Demographics
NPI:1003636416
Name:WILSON, RAFAEL JOSEPH
Entity type:Individual
Prefix:
First Name:RAFAEL
Middle Name:JOSEPH
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 1:3149 PINE LAKE DR
Mailing Address - Street 2:
Mailing Address - City:MEDINA
Mailing Address - State:OH
Mailing Address - Zip Code:44256-9043
Mailing Address - Country:US
Mailing Address - Phone:330-419-9184
Mailing Address - Fax:
Practice Address - Street 1:3149 PINE LAKE DR
Practice Address - Street 2:
Practice Address - City:MEDINA
Practice Address - State:OH
Practice Address - Zip Code:44256-9043
Practice Address - Country:US
Practice Address - Phone:330-419-9184
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-11
Last Update Date:2024-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
No172A00000XOther Service ProvidersDriver