Healthcare Provider Details

I. General information

NPI: 1497030639
Provider Name (Legal Business Name): SETH MACKENZIE WILSON PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2011
Last Update Date: 10/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 S 27TH ST
BILLINGS MT
59101-4200
US

IV. Provider business mailing address

123 S 27TH ST
BILLINGS MT
59101-4200
US

V. Phone/Fax

Practice location:
  • Phone: 406-651-6436
  • Fax:
Mailing address:
  • Phone: 406-651-6436
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number670
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: