Healthcare Provider Details

I. General information

NPI: 1972547552
Provider Name (Legal Business Name): MATTHEW A WILSON PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2006
Last Update Date: 11/16/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

264 PLEASANT ST
CONCORD NH
03301-2551
US

IV. Provider business mailing address

264 PLEASANT STREET
CONCORD NH
03301-2551
US

V. Phone/Fax

Practice location:
  • Phone: 603-224-3368
  • Fax: 603-224-7815
Mailing address:
  • Phone: 603-224-3368
  • Fax: 603-224-7815

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA714
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: