Provider Demographics
NPI:1649013673
Name:WILSON, XAVIER DEON
Entity type:Individual
Prefix:
First Name:XAVIER
Middle Name:DEON
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 1:2210 LINE AVE STE 207
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71104-2134
Mailing Address - Country:US
Mailing Address - Phone:318-675-1112
Mailing Address - Fax:866-307-9980
Practice Address - Street 1:2210 LINE AVE STE 207
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71104-2134
Practice Address - Country:US
Practice Address - Phone:318-675-1112
Practice Address - Fax:866-307-9980
Is Sole Proprietor?:No
Enumeration Date:2024-06-17
Last Update Date:2024-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator