Healthcare Provider Details

I. General information

NPI: 1407871262
Provider Name (Legal Business Name): NICHOLAS RICHARD WILSON PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2006
Last Update Date: 02/26/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8765 LEWIS AVE
TEMPERANCE MI
48182-9583
US

IV. Provider business mailing address

8765 LEWIS AVE
TEMPERANCE MI
48182-9583
US

V. Phone/Fax

Practice location:
  • Phone: 734-847-3802
  • Fax:
Mailing address:
  • Phone: 734-847-3802
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number5601005306
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: