Provider Demographics
NPI:1699145672
Name:FONSECA, WILSON
Entity type:Individual
Prefix:
First Name:WILSON
Middle Name:
Last Name:FONSECA
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 1:4129 BALD EAGLE DR
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34746-2901
Mailing Address - Country:US
Mailing Address - Phone:786-447-4100
Mailing Address - Fax:561-516-6220
Practice Address - Street 1:4129 BALD EAGLE DR
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34746-2901
Practice Address - Country:US
Practice Address - Phone:786-447-4100
Practice Address - Fax:561-516-6220
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-02
Last Update Date:2015-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL163W0000X163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL01531100Medicaid