Provider Demographics
NPI:1215684832
Name:WILSON, BILLY RAY SR
Entity type:Individual
Prefix:
First Name:BILLY
Middle Name:RAY
Last Name:WILSON
Suffix:SR
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 1:902 W BLAIR AVE
Mailing Address - Street 2:
Mailing Address - City:COALGATE
Mailing Address - State:OK
Mailing Address - Zip Code:74538-1206
Mailing Address - Country:US
Mailing Address - Phone:580-927-5588
Mailing Address - Fax:
Practice Address - Street 1:902 W BLAIR AVE
Practice Address - Street 2:
Practice Address - City:COALGATE
Practice Address - State:OK
Practice Address - Zip Code:74538-1206
Practice Address - Country:US
Practice Address - Phone:580-927-5588
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-03
Last Update Date:2022-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Single Specialty