Healthcare Provider Details

I. General information

NPI: 1881939932
Provider Name (Legal Business Name): SCOTT WILSON BC-HIS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2012
Last Update Date: 04/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3030 NW EXPRESSWAY STE 200
OKLAHOMA CITY OK
73112-5466
US

IV. Provider business mailing address

10104 SAMANTHA CT
OKLAHOMA CITY OK
73162-5600
US

V. Phone/Fax

Practice location:
  • Phone: 855-523-9355
  • Fax:
Mailing address:
  • Phone: 405-326-8761
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number804
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: