Healthcare Provider Details

I. General information

NPI: 1265076376
Provider Name (Legal Business Name): BRIAN JOSEPH WILSON NP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/31/2019
Last Update Date: 11/18/2021
Certification Date: 11/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

729 GOLDENROD DR
GARDENDALE AL
35071-2844
US

IV. Provider business mailing address

729 GOLDENROD DR
GARDENDALE AL
35071-2844
US

V. Phone/Fax

Practice location:
  • Phone: 205-240-3925
  • Fax:
Mailing address:
  • Phone: 205-240-3925
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WG0600X
TaxonomyGerontology Registered Nurse
License Number1-131315
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number1-131315
License Number StateAL
# 3
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number1-131315
License Number StateAL
# 4
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number1-131315
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: