Provider Demographics
NPI:1861405805
Name:DAVID WILSON, CST/CFA INC.
Entity type:Organization
Organization Name:DAVID WILSON, CST/CFA INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CAROLYN
Authorized Official - Middle Name:YVONNE
Authorized Official - Last Name:HACKNEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-800-8386
Mailing Address - Street 1:PO BOX 33394
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76162-3394
Mailing Address - Country:US
Mailing Address - Phone:817-800-8386
Mailing Address - Fax:817-295-4992
Practice Address - Street 1:5016 RIVER BLUFF DR
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76132-3710
Practice Address - Country:US
Practice Address - Phone:817-800-8386
Practice Address - Fax:817-295-4992
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXSA0007246ZS0410X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical TechnologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8N4608OtherBCBS OF TX