Healthcare Provider Details

I. General information

NPI: 1629249347
Provider Name (Legal Business Name): MIRIAM J WILBON PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/20/2008
Last Update Date: 02/22/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3330 MASONIC DR
ALEXANDRIA LA
71301-3841
US

IV. Provider business mailing address

PO BOX 1502
LA PLACE LA
70069-1502
US

V. Phone/Fax

Practice location:
  • Phone: 318-487-1122
  • Fax:
Mailing address:
  • Phone: 985-651-8923
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code246QM0706X
TaxonomyMedical Technologist
License NumberG02542
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberA10315
License Number StateLA
# 3
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberA10315
License Number StateLA
# 4
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberA10315
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: