Provider Demographics
NPI:1992434245
Name:WILSON, KAVON
Entity type:Individual
Prefix:
First Name:KAVON
Middle Name:
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 1:3807 ST. BARNABAS RD. #104
Mailing Address - Street 2:
Mailing Address - City:SUITLAND
Mailing Address - State:MD
Mailing Address - Zip Code:20746
Mailing Address - Country:US
Mailing Address - Phone:202-394-4579
Mailing Address - Fax:
Practice Address - Street 1:3807 ST. BARNABAS RD. #104
Practice Address - Street 2:
Practice Address - City:SUITLAND
Practice Address - State:MD
Practice Address - Zip Code:20746
Practice Address - Country:US
Practice Address - Phone:202-394-4579
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-09
Last Update Date:2022-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC4549360Medicaid