Provider Demographics
NPI:1902320773
Name:WILSON, BRIAN (RN)
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:
Last Name:WILSON
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13131 HUTCHINSON WAY
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20906-5948
Mailing Address - Country:US
Mailing Address - Phone:619-886-6342
Mailing Address - Fax:
Practice Address - Street 1:8901 WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20889-0004
Practice Address - Country:US
Practice Address - Phone:301-295-1095
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-02
Last Update Date:2017-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR224388163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDR224388OtherREGISTERED NURSE STATE LICENSE