Provider Demographics
NPI:1801642780
Name:WILSON, BRYANT LAMONT
Entity type:Individual
Prefix:
First Name:BRYANT
Middle Name:LAMONT
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 1:1710 ETHAN WAY
Mailing Address - Street 2:
Mailing Address - City:HEPHZIBAH
Mailing Address - State:GA
Mailing Address - Zip Code:30815-6968
Mailing Address - Country:US
Mailing Address - Phone:912-309-7520
Mailing Address - Fax:
Practice Address - Street 1:1710 ETHAN WAY
Practice Address - Street 2:
Practice Address - City:HEPHZIBAH
Practice Address - State:GA
Practice Address - Zip Code:30815-6968
Practice Address - Country:US
Practice Address - Phone:912-309-7520
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-30
Last Update Date:2024-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)