Healthcare Provider Details

I. General information

NPI: 1275546343
Provider Name (Legal Business Name): DAVID BRADFORD WILSON LSA, CST/CFA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5016 RIVER BLUFF DR
FORT WORTH TX
76132-3710
US

IV. Provider business mailing address

PO BOX 33394
FORT WORTH TX
76162-3394
US

V. Phone/Fax

Practice location:
  • Phone: 817-800-8386
  • Fax: 817-295-4992
Mailing address:
  • Phone: 817-800-8386
  • Fax: 817-295-4992

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZS0410X
TaxonomySurgical Technologist
License NumberSA0007
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: