Provider Demographics
NPI:1447822069
Name:WILSON, MATTHEW LANGSTON
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:LANGSTON
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 1:631 S BROOKHURST ST STE 104
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92804-3510
Mailing Address - Country:US
Mailing Address - Phone:657-250-8135
Mailing Address - Fax:
Practice Address - Street 1:631 S BROOKHURST ST STE 104
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92804-3510
Practice Address - Country:US
Practice Address - Phone:657-233-8236
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-13
Last Update Date:2024-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker