Provider Demographics
NPI:1205447364
Name:WILKINSON, BRYAN DAVID
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:DAVID
Last Name:WILKINSON
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 1:153 E AUBURN TRL
Mailing Address - Street 2:
Mailing Address - City:BRIGHTON
Mailing Address - State:MI
Mailing Address - Zip Code:48114-5011
Mailing Address - Country:US
Mailing Address - Phone:616-287-2257
Mailing Address - Fax:
Practice Address - Street 1:153 E AUBURN TRL
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:MI
Practice Address - Zip Code:48114-5011
Practice Address - Country:US
Practice Address - Phone:616-287-2257
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-12
Last Update Date:2020-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, OtherGroup - Single Specialty