MEDICARE: MR. HOWARD RENFORD WILSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1275898082
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. HOWARD RENFORD WILSON

Provider Business Mailing Address
First Line	:	3318 N DECATUR BLVD UNIT 1301
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89130-3240
Country	:	US
Telephone Number	:	702-756-5205
Fax Number	:	702-463-5982

Provider Business Practice Location Address
First Line	:	3318 N DECATUR BLVD UNIT 1301
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89130-3240
Country	:	US
Telephone Number	:	702-756-5205
Fax Number	:	702-463-5982

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/08/2012
Last Update Date	:	07/08/2012

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