Individual
MR. MATTHEW J WILSON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
LMT
Contact information
Practice address
119 BEAL PKWY SE, SUITE 101, FORT WALTON BEACH, FL 32548-5386
(850) 598-3633
Mailing address
119 BEAL PKWY SE, SUITE 101, FORT WALTON BEACH, FL 32548-5386
(850) 598-3633
Taxonomy
Speciality
Code
Description
License number
State
247200000X
Other Technician
Primary
MA33164
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
C2463
BLUE CROSS & BLUE SHIELD
FL
Enumeration date
02/19/2008
Last updated
02/19/2008
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