Healthcare Provider Details

I. General information

NPI: 1821520479
Provider Name (Legal Business Name): OLIVER WILSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/03/2017
Last Update Date: 04/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1153 OAK ST
SAN FRANCISCO CA
94117-2216
US

IV. Provider business mailing address

1153 OAK ST
SAN FRANCISCO CA
94117-2216
US

V. Phone/Fax

Practice location:
  • Phone: 415-431-9000
  • Fax: 415-431-1813
Mailing address:
  • Phone: 415-431-9000
  • Fax: 415-431-1813

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: