Healthcare Provider Details

I. General information

NPI: 1144781568
Provider Name (Legal Business Name): NICHOLAS ANTHONY WILSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2019
Last Update Date: 09/17/2026
Certification Date: 09/17/2026
Deactivation Date: 10/13/2023
Reactivation Date: 10/20/2023

III. Provider practice location address

1220 DEWEY AVE
WAUWATOSA WI
53213-2504
US

IV. Provider business mailing address

PO BOX 735044
CHICAGO IL
60673-5044
US

V. Phone/Fax

Practice location:
  • Phone: 262-829-2441
  • Fax:
Mailing address:
  • Phone: 800-326-2250
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number81247-21
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: