Individual
DR. BRENT WILSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
1303 E HERNDON AVE, FRESNO, CA 93720-3309
(559) 450-3205
Mailing address
PO BOX 6089, PORTLAND, OR 97228-6089
(888) 398-1370
Taxonomy
Speciality
Code
Description
License number
State
207P00000X
Emergency Medicine Physician
Primary
A84254
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
00A842540
BLUE SHIELD
CA
05
—
00A842540
—
CA
01
—
A84254
BLUE CROSS
CA
01
—
A84254
COUNTY OF FRESNO
—
Enumeration date
07/25/2006
Last updated
12/05/2007
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