Healthcare Provider Details

I. General information

NPI: 1316245764
Provider Name (Legal Business Name): ANTHONY BRADFORD WILSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/09/2011
Last Update Date: 03/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7219 N LITCHFIELD RD
GLENDALE AZ
85309-1529
US

IV. Provider business mailing address

16654 N 178TH AVE
SURPRISE AZ
85388-1798
US

V. Phone/Fax

Practice location:
  • Phone: 623-856-2793
  • Fax:
Mailing address:
  • Phone: 623-221-1089
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1003X
TaxonomyIndependent Duty Medical Technicians
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: