Healthcare Provider Details

I. General information

NPI: 1912419276
Provider Name (Legal Business Name): ALIX MACKENZIE WILSON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2017
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

747 52ND ST
OAKLAND CA
94609-1809
US

IV. Provider business mailing address

2207 BRIDGEPORT WAY
MARTINEZ CA
94553-6711
US

V. Phone/Fax

Practice location:
  • Phone: 203-570-0111
  • Fax:
Mailing address:
  • Phone: 203-570-0111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA55025
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA55025
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code2080S0010X
TaxonomyPediatric Sports Medicine Physician
License Number55025
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: