MEDICARE: MR. INYANG E WILSON PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	PA00933	TX

General Provider Information

NPI Number	:	1053359885
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. INYANG E WILSON PA

Provider Business Mailing Address
First Line	:	PO BOX 921
Second Line	:
City	:	FRESNO
State	:	TX
Zip	:	77545-0921
Country	:	US
Telephone Number	:	979-871-9453
Fax Number	:	979-871-9429

Provider Business Practice Location Address
First Line	:	606 N GULF BLVD
Second Line	:
City	:	FREEPORT
State	:	TX
Zip	:	77541-3902
Country	:	US
Telephone Number	:	979-871-9354
Fax Number	:	979-871-9429

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/03/2006
Last Update Date	:	06/17/2013

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