Provider Demographics
NPI:1124764527
Name:WILSON, ANDREO
Entity type:Individual
Prefix:MR
First Name:ANDREO
Middle Name:
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 1:161 ROSE LN
Mailing Address - Street 2:
Mailing Address - City:DRAKES BRANCH
Mailing Address - State:VA
Mailing Address - Zip Code:23937-2508
Mailing Address - Country:US
Mailing Address - Phone:434-515-1805
Mailing Address - Fax:
Practice Address - Street 1:161 ROSE LN
Practice Address - Street 2:
Practice Address - City:DRAKES BRANCH
Practice Address - State:VA
Practice Address - Zip Code:23937-2508
Practice Address - Country:US
Practice Address - Phone:434-515-1805
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-09
Last Update Date:2023-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA30017448820001Medicaid
VA30017448820002Medicaid