MEDICARE: MR. DEVONTE ISIAH WILSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3747P1801X	Personal Care Attendant

General Provider Information

NPI Number	:	1831693977
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. DEVONTE ISIAH WILSON

Provider Business Mailing Address
First Line	:	2834 Q ST SE
Second Line	:
City	:	WASHINGTON
State	:	DC
Zip	:	20020-3804
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2834 Q ST SE
Second Line	:
City	:	WASHINGTON
State	:	DC
Zip	:	20020-3804
Country	:	US
Telephone Number	:	240-273-2042
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/22/2018
Last Update Date	:	03/22/2018

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Directions to “ MR. DEVONTE ISIAH WILSON ” Practice Location

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