Basic Information
| Provider Information | |||||||||
| NPI: | 1952509408 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | ADRIAN | ||||||||
| MiddleName: | I. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 151 | ||||||||
| Address2: | |||||||||
| City: | NEW CASTLE | ||||||||
| State: | DE | ||||||||
| PostalCode: | 197200151 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3026522455 | ||||||||
| FaxNumber: | 3023226251 | ||||||||
| Practice Location | |||||||||
| Address1: | 908 E 16TH ST STE B | ||||||||
| Address2: | |||||||||
| City: | WILMINGTON | ||||||||
| State: | DE | ||||||||
| PostalCode: | 198025145 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3025751414 | ||||||||
| FaxNumber: | 3025751726 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2007 | ||||||||
| LastUpdateDate: | 12/02/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 12/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | C2-0008403 | DE | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1952509408 | 05 | DE | MEDICAID | C2-0008403 | 01 | DE | MEDICAL LICENSE | OTHER |