Healthcare Provider Details

I. General information

NPI: 1972326536
Provider Name (Legal Business Name): MICHAEL JAMES WILSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/04/2024
Last Update Date: 12/22/2025
Certification Date: 12/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1364 CLIFTON RD NE
ATLANTA GA
30322-1059
US

IV. Provider business mailing address

1700 WELIKA DR
DECATUR GA
30032-4330
US

V. Phone/Fax

Practice location:
  • Phone: 404-778-3900
  • Fax:
Mailing address:
  • Phone: 619-733-5584
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367H00000X
TaxonomyAnesthesiologist Assistant
License Number12900
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: