Basic Information
| Provider Information | |||||||||
| NPI: | 1780601252 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | BRETT | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | II | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 10040 | ||||||||
| Address2: | |||||||||
| City: | WESTMINSTER | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926850040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5628093528 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 300 W PUEBLO ST | ||||||||
| Address2: | |||||||||
| City: | SANTA BARBARA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 931054311 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8056827111 | ||||||||
| FaxNumber: | 8055698368 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2006 | ||||||||
| LastUpdateDate: | 04/01/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | MD.026108 | LA | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | A97199 | CA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00A971990 | 05 | CA | MEDICAID |