Healthcare Provider Details

I. General information

NPI: 1376776831
Provider Name (Legal Business Name): AMBER WILSON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2009
Last Update Date: 05/11/2021
Certification Date: 05/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 N WINFIELD RD STE 424
WINFIELD IL
60190-1379
US

IV. Provider business mailing address

25 N WINFIELD RD STE 424
WINFIELD IL
60190-1379
US

V. Phone/Fax

Practice location:
  • Phone: 630-933-4056
  • Fax: 630-933-4057
Mailing address:
  • Phone: 630-933-4056
  • Fax: 630-933-4057

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number5601005578
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberMA056675
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085005692
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: