=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881662963
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRETT WILSON DO
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/14/2006
-----------------------------------------------------
Last Update Date | 01/11/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1418 JAMESWAY
-----------------------------------------------------
City | FORT ATKINSON
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53538-2800
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-568-0488
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1418 JAMESWAY
-----------------------------------------------------
City | FORT ATKINSON
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53538-2800
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 23305
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------