Provider Demographics
NPI:1689207292
Name:WILSON, BRANDON (CNP)
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:
Last Name:WILSON
Suffix:
Gender:M
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1320 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:OH
Mailing Address - Zip Code:43055-1822
Mailing Address - Country:US
Mailing Address - Phone:220-564-4475
Mailing Address - Fax:220-564-4412
Practice Address - Street 1:1320 W MAIN ST
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:OH
Practice Address - Zip Code:43055-1822
Practice Address - Country:US
Practice Address - Phone:220-564-4475
Practice Address - Fax:220-564-4412
Is Sole Proprietor?:No
Enumeration Date:2020-02-21
Last Update Date:2022-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH026226363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily