Healthcare Provider Details

I. General information

NPI: 1437982824
Provider Name (Legal Business Name): STEPHEN R WILSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/22/2024
Last Update Date: 08/22/2024
Certification Date: 08/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

459 PATTERSON RD
HONOLULU HI
96819-1522
US

IV. Provider business mailing address

459 PATTERSON RD
HONOLULU HI
96819-1522
US

V. Phone/Fax

Practice location:
  • Phone: 859-361-1834
  • Fax: 808-433-7744
Mailing address:
  • Phone: 859-361-1834
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number268575
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number28168656A
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number113438
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: