Healthcare Provider Details

I. General information

NPI: 1114672664
Provider Name (Legal Business Name): MAXWELL FRANKLIN WILSON II PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/14/2022
Last Update Date: 09/16/2024
Certification Date: 09/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1509 DOCTORS CIR BLDG C
WILMINGTON NC
28401-7403
US

IV. Provider business mailing address

PO BOX 936857
ATLANTA GA
31193-6857
US

V. Phone/Fax

Practice location:
  • Phone: 910-662-7500
  • Fax: 910-662-7501
Mailing address:
  • Phone: 910-662-7500
  • Fax: 910-662-7501

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-11978
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number0010-11978
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: