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General NPI Number Information
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NPI Number | 1417769001
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Entity Type | Individual
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Provider Name | BRIAN EVANS WILSON CPSW
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Gender | Male
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Dates
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Enumeration Date | 01/22/2025
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Last Update Date | 01/22/2025
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Provider Practice Location Address
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Address Line | 309 S. CHINO LOOP
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City | GAMERCO
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State | NM
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Zip | 87317
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Country | US
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Telephone | 505-488-2380
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 3809
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City | GALLUP
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State | NM
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Zip | 87305-3809
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Country | US
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Telephone | 505-870-9868
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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 | 175T00000X
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Taxonomy Name | Peer Specialist
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License Number | 1476
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License Number State | NM
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