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NPI Code Detail

MEDICARE: MR. JOE RANDALL WILSON LPT

MEDICARE: MR. JOE RANDALL WILSON LPT
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
1167G00000XLicensed Psychiatric Technician

General Provider Information

NPI Number : 1922167345
Entity Type Code : Individual
Provider Name (Legal Business Name) : MR. JOE RANDALL WILSON LPT
Provider Business Mailing Address
First Line : 2171 N FINE AVE
Second Line :
City : FRESNO
State : CA
Zip : 93727-1519
Country : US
Telephone Number : 559-455-2000
Fax Number : 559-455-2041
Provider Business Practice Location Address
First Line : 2171 N FINE AVE
Second Line :
City : FRESNO
State : CA
Zip : 93727-1519
Country : US
Telephone Number : 559-455-2000
Fax Number : 559-455-2041
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 12/08/2006
Last Update Date : 07/08/2007

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Directions to “ MR. JOE RANDALL WILSON LPT” Practice Location

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