Provider Demographics
NPI:1699459594
Name:FERGUSON, WILSON III (MS)
Entity type:Individual
Prefix:
First Name:WILSON
Middle Name:
Last Name:FERGUSON
Suffix:III
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1418 TIGER DR
Mailing Address - Street 2:
Mailing Address - City:THIBODAUX
Mailing Address - State:LA
Mailing Address - Zip Code:70301-4337
Mailing Address - Country:US
Mailing Address - Phone:985-449-4055
Mailing Address - Fax:985-449-4178
Practice Address - Street 1:1418 TIGER DR
Practice Address - Street 2:
Practice Address - City:THIBODAUX
Practice Address - State:LA
Practice Address - Zip Code:70301-4337
Practice Address - Country:US
Practice Address - Phone:985-449-4055
Practice Address - Fax:985-449-4178
Is Sole Proprietor?:No
Enumeration Date:2023-06-12
Last Update Date:2023-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
LA009497183172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
No171M00000XOther Service ProvidersCase Manager/Care Coordinator