Healthcare Provider Details

I. General information

NPI: 1558738963
Provider Name (Legal Business Name): GRANT WILSON PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/02/2015
Last Update Date: 09/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

802 KENYON RD
FORT DODGE IA
50501-5740
US

IV. Provider business mailing address

802 KENYON RD
FORT DODGE IA
50501-5740
US

V. Phone/Fax

Practice location:
  • Phone: 515-573-3101
  • Fax:
Mailing address:
  • Phone: 515-573-3101
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number079688
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: