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General NPI Number Information
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NPI Number | 1508339987
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Entity Type | Individual
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Provider Name | BRADLEY RUSSELL WILSON FNP
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Gender | Male
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Dates
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Enumeration Date | 01/08/2019
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Last Update Date | 01/08/2019
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Provider Practice Location Address
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Address Line | 22101 MOROSS RD
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City | DETROIT
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State | MI
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Zip | 48236-2148
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Country | US
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Telephone | 313-343-3660
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Fax |
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Provider Business Mailing Address
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Address Line | 36251 ALFRED ST
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City | NEW BALTIMORE
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State | MI
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Zip | 48047-2106
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Country | US
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Telephone | 586-840-6016
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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 | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 470429662
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License Number State | MI
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