Healthcare Provider Details

I. General information

NPI: 1386727006
Provider Name (Legal Business Name): NATHAN A. WILSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2006
Last Update Date: 06/08/2020
Certification Date: 06/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3485 MIKE PADGETT HWY
AUGUSTA GA
30906-3815
US

IV. Provider business mailing address

6531 RIVER BLUFF TRL
MARTINEZ GA
30907-3317
US

V. Phone/Fax

Practice location:
  • Phone: 706-771-7843
  • Fax:
Mailing address:
  • Phone: 706-831-5834
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number057203
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: