Basic Information
| Provider Information | |||||||||
| NPI: | 1518329887 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | BRYAN | ||||||||
| MiddleName: | SCOTT | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1564 SELBY AVE APT 8 | ||||||||
| Address2: | |||||||||
| City: | SAINT PAUL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551046336 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 265 GRIFFIN ST E | ||||||||
| Address2: | |||||||||
| City: | AMERY | ||||||||
| State: | WI | ||||||||
| PostalCode: | 540011439 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7152688000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2016 | ||||||||
| LastUpdateDate: | 09/21/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 63432 | MN | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 2084P0800X | 69464-21 | WI | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
No ID Information.