Healthcare Provider Details

I. General information

NPI: 1063443984
Provider Name (Legal Business Name): PAUL WILSON NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2006
Last Update Date: 01/31/2025
Certification Date: 01/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 MERCY CIRCLE
CAMP PENDLETON CA
92055
US

IV. Provider business mailing address

162 1ST ST
PORT HUENEME CA
93043-4316
US

V. Phone/Fax

Practice location:
  • Phone: 805-982-6362
  • Fax:
Mailing address:
  • Phone: 805-982-6362
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number12242
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: