Basic Information
| Provider Information | |||||||||
| NPI: | 1457847451 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | AUBREY | ||||||||
| MiddleName: | LINN | ||||||||
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| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 118 CASS AVE | ||||||||
| Address2: | |||||||||
| City: | MOUNT CLEMENS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480432204 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5864687370 | ||||||||
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| Practice Location | |||||||||
| Address1: | 8212 N LINDBERGH BLVD | ||||||||
| Address2: | |||||||||
| City: | FLORISSANT | ||||||||
| State: | MO | ||||||||
| PostalCode: | 630317107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3148312221 | ||||||||
| FaxNumber: | 3148310199 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/03/2018 | ||||||||
| LastUpdateDate: | 11/19/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 2018021081 | MO | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 1194879023 | 05 | MI | MEDICAID |