Provider Demographics
NPI:1417769001
Name:WILSON, BRIAN EVANS (CPSW)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:EVANS
Last Name:WILSON
Suffix:
Gender:M
Credentials:CPSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3809
Mailing Address - Street 2:
Mailing Address - City:GALLUP
Mailing Address - State:NM
Mailing Address - Zip Code:87305-3809
Mailing Address - Country:US
Mailing Address - Phone:505-870-9868
Mailing Address - Fax:
Practice Address - Street 1:309 S. CHINO LOOP
Practice Address - Street 2:
Practice Address - City:GAMERCO
Practice Address - State:NM
Practice Address - Zip Code:87317
Practice Address - Country:US
Practice Address - Phone:505-488-2380
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-22
Last Update Date:2025-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1476175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist