Provider Demographics
NPI:1780288597
Name:WILSON, MARK ALLEN
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:ALLEN
Last Name:WILSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6706 CHARLESGATE RD
Mailing Address - Street 2:
Mailing Address - City:HUBER HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:45424-7077
Mailing Address - Country:US
Mailing Address - Phone:937-829-8808
Mailing Address - Fax:
Practice Address - Street 1:6706 CHARLESGATE RD
Practice Address - Street 2:
Practice Address - City:HUBER HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:45424-7077
Practice Address - Country:US
Practice Address - Phone:937-829-8808
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-23
Last Update Date:2020-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes376J00000XNursing Service Related ProvidersHomemakerGroup - Multi-Specialty