Healthcare Provider Details

I. General information

NPI: 1033757638
Provider Name (Legal Business Name): WILSON MEDICAL STAFFING PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2019
Last Update Date: 01/12/2021
Certification Date: 01/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2603 KENTUCKY AVE STE 305
PADUCAH KY
42003-3814
US

IV. Provider business mailing address

PO BOX 9485
PADUCAH KY
42002-9485
US

V. Phone/Fax

Practice location:
  • Phone: 270-558-5456
  • Fax: 270-558-5471
Mailing address:
  • Phone: 270-558-5456
  • Fax: 270-558-5471

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: DR. RICHARD SCOTT WILSON
Title or Position: MEMBER/MANAGER
Credential: MD
Phone: 270-558-5456