Healthcare Provider Details

I. General information

NPI: 1003636416
Provider Name (Legal Business Name): RAFAEL JOSEPH WILSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/11/2024
Last Update Date: 10/11/2024
Certification Date: 10/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3149 PINE LAKE DR
MEDINA OH
44256-9043
US

IV. Provider business mailing address

3149 PINE LAKE DR
MEDINA OH
44256-9043
US

V. Phone/Fax

Practice location:
  • Phone: 330-419-9184
  • Fax:
Mailing address:
  • Phone: 330-419-9184
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376J00000X
TaxonomyHomemaker
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code172A00000X
TaxonomyDriver
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: