Healthcare Provider Details

I. General information

NPI: 1073234787
Provider Name (Legal Business Name): MYRICK J WILSON JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2022
Last Update Date: 09/09/2022
Certification Date: 09/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1788 CELESTE AVE
CLOVIS CA
93611-2069
US

IV. Provider business mailing address

1826 S DELNO AVE
FRESNO CA
93706-3550
US

V. Phone/Fax

Practice location:
  • Phone: 559-243-7002
  • Fax:
Mailing address:
  • Phone: 559-307-2765
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: