Provider Demographics
NPI:1801130489
Name:WILSON, THOMAS L (RN)
Entity type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:L
Last Name:WILSON
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 DANIEL LOW TER APT 4K
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10301-1740
Mailing Address - Country:US
Mailing Address - Phone:888-554-3810
Mailing Address - Fax:206-426-0930
Practice Address - Street 1:255 GORDON ST
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10304-1943
Practice Address - Country:US
Practice Address - Phone:888-554-3810
Practice Address - Fax:206-426-0930
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-20
Last Update Date:2012-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY579666163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management