Provider Demographics
NPI:1871536318
Name:WILSON, BRET ALAN (DC)
Entity type:Individual
Prefix:DR
First Name:BRET
Middle Name:ALAN
Last Name:WILSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14192 W DESERT HILLS DR
Mailing Address - Street 2:
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85379-4902
Mailing Address - Country:US
Mailing Address - Phone:623-337-5778
Mailing Address - Fax:
Practice Address - Street 1:16846 W BELL RD
Practice Address - Street 2:SUITE 112
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85374-3052
Practice Address - Country:US
Practice Address - Phone:623-556-2335
Practice Address - Fax:623-556-9382
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-13
Last Update Date:2010-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ7609111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0452013Medicaid
OHWI0490882Medicare PIN
OHT47248Medicare UPIN