Healthcare Provider Details

I. General information

NPI: 1902494065
Provider Name (Legal Business Name): MCKENNA LEIGH WILSON PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/05/2021
Last Update Date: 07/21/2022
Certification Date: 07/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1080 OAKLAND AVE
PLAINFIELD NJ
07060-3434
US

IV. Provider business mailing address

1080 OAKLAND AVE
PLAINFIELD NJ
07060-3434
US

V. Phone/Fax

Practice location:
  • Phone: 908-255-8626
  • Fax:
Mailing address:
  • Phone: 908-255-8626
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number028008
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: