Healthcare Provider Details

I. General information

NPI: 1184158172
Provider Name (Legal Business Name): MATTHEW JAMES WILSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2017
Last Update Date: 06/17/2022
Certification Date: 06/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 AUDUBON PLAZA DR
LOUISVILLE KY
40217-1318
US

IV. Provider business mailing address

3 AUDUBON PLAZA DR STE 340
LOUISVILLE KY
40217-1319
US

V. Phone/Fax

Practice location:
  • Phone: 502-634-6767
  • Fax:
Mailing address:
  • Phone: 502-634-6767
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberTP727
License Number StateKY
# 3
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number56990
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: