MEDICARE: DEZIRAE 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	3747P1801X	Personal Care Attendant

General Provider Information

NPI Number	:	1902425523
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEZIRAE WILSON

Provider Business Mailing Address
First Line	:	1005 TERMINAL WAY STE 125
Second Line	:
City	:	RENO
State	:	NV
Zip	:	89502-2198
Country	:	US
Telephone Number	:	877-786-4999
Fax Number	:

Provider Business Practice Location Address
First Line	:	5180 E TROPICANA AVE APT 46E
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89122
Country	:	US
Telephone Number	:	702-469-1394
Fax Number	:

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

Provider Enumeration Date	:	04/14/2020
Last Update Date	:	04/14/2020

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Directions to “ DEZIRAE WILSON ” Practice Location

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