Basic Information
| Provider Information | |||||||||
| NPI: | 1972985299 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | BRYAN | ||||||||
| MiddleName: | RICHARD | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 801 OSTRUM ST | ||||||||
| Address2: | |||||||||
| City: | BETHLEHEM | ||||||||
| State: | PA | ||||||||
| PostalCode: | 180151000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4845264903 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 801 OSTRUM ST | ||||||||
| Address2: | |||||||||
| City: | BETHLEHEM | ||||||||
| State: | PA | ||||||||
| PostalCode: | 18015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4845264903 | ||||||||
| FaxNumber: | 4845262153 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/23/2015 | ||||||||
| LastUpdateDate: | 09/28/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207PE0004X | 30830 | WV | N | Allopathic & Osteopathic Physicians | Emergency Medicine | Emergency Medical Services | 207P00000X | MD461810 | PA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | MT209074 | PA | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207PE0004X | 25MA10245300 | NJ | N | Allopathic & Osteopathic Physicians | Emergency Medicine | Emergency Medical Services |
No ID Information.