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General NPI Number Information
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NPI Number | 1518313089
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Entity Type | Individual
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Provider Name | MARK WILSON IDMT
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Gender | Male
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Dates
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Enumeration Date | 05/13/2016
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Last Update Date | 05/13/2016
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Provider Practice Location Address
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Address Line | 1101 GRADE LN 123 SPECIAL TACTICS
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City | LOUISVILLE
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State | KY
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Zip | 40213-2673
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Country | US
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Telephone | 502-413-4836
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Fax |
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Provider Business Mailing Address
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Address Line | 2200 MAMMOTH WAY
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City | LOUISVILLE
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State | KY
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Zip | 40299-2611
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Country | US
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Telephone | 502-472-1274
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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 | 1710I1003X
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Taxonomy Name | Independent Duty Medical Technicians
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License Number |
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License Number State |
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