Individual
MARK WILSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
IDMT
Contact information
Practice address
1101 GRADE LN, 123 SPECIAL TACTICS, LOUISVILLE, KY 40213-2673
(502) 413-4836
Mailing address
2200 MAMMOTH WAY, LOUISVILLE, KY 40299-2611
(502) 472-1274
Taxonomy
Speciality
Code
Description
License number
State
1710I1003X
Independent Duty Medical Technicians
Primary
—
—
Other
Enumeration date
05/13/2016
Last updated
05/13/2016
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