Provider Demographics
NPI:1801231915
Name:WILSON, BILLY DWAYNE
Entity type:Individual
Prefix:
First Name:BILLY
Middle Name:DWAYNE
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 1:1208 MADISON TER
Mailing Address - Street 2:
Mailing Address - City:GLENN HEIGHTS
Mailing Address - State:TX
Mailing Address - Zip Code:75154-8833
Mailing Address - Country:US
Mailing Address - Phone:214-557-5512
Mailing Address - Fax:972-274-0811
Practice Address - Street 1:1208 MADISON TER
Practice Address - Street 2:
Practice Address - City:GLENN HEIGHTS
Practice Address - State:TX
Practice Address - Zip Code:75154-8833
Practice Address - Country:US
Practice Address - Phone:214-557-5512
Practice Address - Fax:972-274-0811
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-02
Last Update Date:2013-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171WH0202XOther Service ProvidersContractorHome Modifications