Individual
MR. EVAN JONATHAN WILSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
IDC
Contact information
Practice address
2989 EAST AROW ST, YUMA, AZ 85365
(310) 408-7127
Mailing address
1617 E REILLY ST, APT C, YUMA, AZ 85365-5659
(310) 408-7127
Taxonomy
Speciality
Code
Description
License number
State
1710I1002X
Independent Duty Corpsman
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1124648471
US NAVY
CA
Enumeration date
06/22/2015
Last updated
09/16/2015
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