Provider Demographics
NPI:1447259569
Name:WILSON, BASIL ALEXANDER (ARNP)
Entity type:Individual
Prefix:MR
First Name:BASIL
Middle Name:ALEXANDER
Last Name:WILSON
Suffix:
Gender:M
Credentials:ARNP
Other - Prefix:MR
Other - First Name:BASIL
Other - Middle Name:A
Other - Last Name:WILSOM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:ARNP, FNP, BC, MS,
Mailing Address - Street 1:4863 FOXRUN CIR
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33813-2229
Mailing Address - Country:US
Mailing Address - Phone:954-260-7525
Mailing Address - Fax:
Practice Address - Street 1:1801 CRYSTAL LAKE DR
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33801-5979
Practice Address - Country:US
Practice Address - Phone:863-937-8886
Practice Address - Fax:863-937-8892
Is Sole Proprietor?:No
Enumeration Date:2005-07-20
Last Update Date:2013-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP 2068702363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL303424100Medicaid
FL034712822OtherANCC NATIONAL CERT.
FLARNP 2068702OtherLICENSE NUMBER