Healthcare Provider Details

I. General information

NPI: 1093265225
Provider Name (Legal Business Name): ASHLEY LAUREN WILSON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ASHLEY LAUREN WILSON PA-C

II. Dates (important events)

Enumeration Date: 10/12/2016
Last Update Date: 06/27/2025
Certification Date: 06/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

940 RIVER CENTRE DR
PORT HURON MI
48060-4463
US

IV. Provider business mailing address

940 RIVER CENTRE DR
PORT HURON MI
48060-4463
US

V. Phone/Fax

Practice location:
  • Phone: 810-985-4900
  • Fax: 810-985-3634
Mailing address:
  • Phone: 810-985-4900
  • Fax: 810-985-3634

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number56010078889
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: