Provider Demographics
NPI:1881452019
Name:WILSON, SAMUEL CARL (PRS)
Entity type:Individual
Prefix:MR
First Name:SAMUEL
Middle Name:CARL
Last Name:WILSON
Suffix:
Gender:M
Credentials:PRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 HAWTHORNE LN
Mailing Address - Street 2:
Mailing Address - City:WILLINGBORO
Mailing Address - State:NJ
Mailing Address - Zip Code:08046-1717
Mailing Address - Country:US
Mailing Address - Phone:609-470-4283
Mailing Address - Fax:
Practice Address - Street 1:15 HAWTHORNE LN
Practice Address - Street 2:
Practice Address - City:WILLINGBORO
Practice Address - State:NJ
Practice Address - Zip Code:08046-1717
Practice Address - Country:US
Practice Address - Phone:609-470-4283
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-12
Last Update Date:2024-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist