Provider Demographics
NPI:1952015083
Name:WILSON, LUKE
Entity Type:Individual
Prefix:
First Name:LUKE
Middle Name:
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 1:32196 SW JOHNSON SCHOOL RD
Mailing Address - Street 2:
Mailing Address - City:CORNELIUS
Mailing Address - State:OR
Mailing Address - Zip Code:97113-6224
Mailing Address - Country:US
Mailing Address - Phone:503-915-6917
Mailing Address - Fax:
Practice Address - Street 1:32196 SW JOHNSON SCHOOL RD
Practice Address - Street 2:
Practice Address - City:CORNELIUS
Practice Address - State:OR
Practice Address - Zip Code:97113-6224
Practice Address - Country:US
Practice Address - Phone:503-915-6917
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-12
Last Update Date:2023-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider