Healthcare Provider Details

I. General information

NPI: 1285477653
Provider Name (Legal Business Name): EDGAR HAROLD WILSON-BOWER PRS/PSR/TCM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2024
Last Update Date: 06/14/2024
Certification Date: 06/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 FINNEY BOULEVARD SUITE 150
MALONE NY
12953-1340
US

IV. Provider business mailing address

PO BOX 608
MALONE NY
12953-0608
US

V. Phone/Fax

Practice location:
  • Phone: 518-481-8160
  • Fax: 518-481-8161
Mailing address:
  • Phone: 518-483-1251
  • Fax: 518-483-2242

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: