Healthcare Provider Details

I. General information

NPI: 1518329887
Provider Name (Legal Business Name): BRYAN SCOTT WILSON D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2016
Last Update Date: 09/21/2020
Certification Date: 09/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

265 GRIFFIN ST E
AMERY WI
54001-1439
US

IV. Provider business mailing address

1564 SELBY AVE APT 8
SAINT PAUL MN
55104-6336
US

V. Phone/Fax

Practice location:
  • Phone: 715-268-8000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number63432
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number69464-21
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: