Provider Demographics
NPI:1386694792
Name:WILSON, JOHN ANTHONY
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:ANTHONY
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 1:9022 S COLFAX AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60617-4025
Mailing Address - Country:US
Mailing Address - Phone:773-995-7858
Mailing Address - Fax:
Practice Address - Street 1:2 W 115TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60628-5512
Practice Address - Country:US
Practice Address - Phone:773-995-0638
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILW42546178287374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide