Healthcare Provider Details

I. General information

NPI: 1720268493
Provider Name (Legal Business Name): TYRONE NATHANIEL WILSON BSN., LPN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/09/2007
Last Update Date: 11/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16 SUMMER VALE CT
COLUMBIA SC
29223-7861
US

IV. Provider business mailing address

16 SUMMER VALE CT
COLUMBIA SC
29223-7861
US

V. Phone/Fax

Practice location:
  • Phone: 803-331-8518
  • Fax:
Mailing address:
  • Phone: 803-331-8518
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number34333
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: