Healthcare Provider Details

I. General information

NPI: 1063374627
Provider Name (Legal Business Name): MEGAN WILSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/02/2025
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1760 E KEN PRATT BLVD STE 205
LONGMONT CO
80504-5311
US

IV. Provider business mailing address

1760 E KEN PRATT BLVD STE 205
LONGMONT CO
80504-5311
US

V. Phone/Fax

Practice location:
  • Phone: 720-718-3930
  • Fax: 720-718-0939
Mailing address:
  • Phone: 720-718-3930
  • Fax: 720-718-0939

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPN.1001512-NP
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberF09251457
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: