Healthcare Provider Details

I. General information

NPI: 1306811567
Provider Name (Legal Business Name): RYAN M WILSON PA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/21/2006
Last Update Date: 12/01/2023
Certification Date: 12/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1350 HICKORY ST
MELBOURNE FL
32901-3224
US

IV. Provider business mailing address

3300 S FISKE BLVD
ROCKLEDGE FL
32955-4306
US

V. Phone/Fax

Practice location:
  • Phone: 321-434-1401
  • Fax: 321-434-1667
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberP9102044
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA9102044
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: