Provider Demographics
NPI:1043029531
Name:WILSON, BRANDON ANTYWAN
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:ANTYWAN
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 1:1233 SHADOW MOSS LN
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68521-8600
Mailing Address - Country:US
Mailing Address - Phone:402-802-1544
Mailing Address - Fax:
Practice Address - Street 1:1233 SHADOW MOSS LN
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68521-8600
Practice Address - Country:US
Practice Address - Phone:402-802-1544
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-30
Last Update Date:2024-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
No372500000XNursing Service Related ProvidersChore Provider
No372600000XNursing Service Related ProvidersAdult Companion
No373H00000XNursing Service Related ProvidersDay Training/Habilitation Specialist
No385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child