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General NPI Number Information
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NPI Number | 1316210131
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Entity Type | Individual
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Provider Name | DANIEL MARK WILSON JR. RPA-C
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Gender | Male
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Dates
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Enumeration Date | 02/10/2012
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Last Update Date | 02/22/2012
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Provider Practice Location Address
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Address Line | 1000 MONTAUK HWY
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City | WEST ISLIP
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State | NY
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Zip | 11795-4927
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Country | US
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Telephone | 631-376-4444
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Fax |
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Provider Business Mailing Address
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Address Line | 20 MALLARD RD
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City | LEVITTOWN
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State | NY
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Zip | 11756-4204
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AS0400X
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Taxonomy Name | Surgical Physician Assistant
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License Number | 015362-1
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License Number State | NY
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