Healthcare Provider Details

I. General information

NPI: 1467014456
Provider Name (Legal Business Name): WINSTON WILSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/01/2019
Last Update Date: 07/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

618 BRYAN DR
DURANT OK
74701-3462
US

IV. Provider business mailing address

2220 WILSON ST
DURANT OK
74701-5517
US

V. Phone/Fax

Practice location:
  • Phone: 580-920-0909
  • Fax:
Mailing address:
  • Phone: 580-230-8828
  • Fax:

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: