Provider Demographics
NPI:1235956202
Name:WILSON, MATTHEW R
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:R
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 1:53 SCENIC HWY
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30046-5728
Mailing Address - Country:US
Mailing Address - Phone:470-344-9271
Mailing Address - Fax:
Practice Address - Street 1:53 SCENIC HWY
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-5728
Practice Address - Country:US
Practice Address - Phone:470-344-9271
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-23
Last Update Date:2024-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide