MEDICARE: DR. NATHAN JEROME WILSON D.O.

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	207Q00000X	Family Medicine Physician	20A5796	CA

General Provider Information

NPI Number	:	1720053572
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. NATHAN JEROME WILSON D.O.

Provider Business Mailing Address
First Line	:	4221 CHESTNUT AVE
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90807-1903
Country	:	US
Telephone Number	:	310-720-0758
Fax Number	:

Provider Business Practice Location Address
First Line	:	4221 CHESTNUT AVE
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90807-1903
Country	:	US
Telephone Number	:	310-720-0758
Fax Number	:

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

Provider Enumeration Date	:	02/22/2006
Last Update Date	:	02/11/2015

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