Healthcare Provider Details

I. General information

NPI: 1093263105
Provider Name (Legal Business Name): MATTHEW WILHELM PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/18/2016
Last Update Date: 12/05/2025
Certification Date: 12/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2211 LOMAS BLVD NE
ALBUQUERQUE NM
87106-2719
US

IV. Provider business mailing address

2110 LEAD AVE SE
ALBUQUERQUE NM
87106-4008
US

V. Phone/Fax

Practice location:
  • Phone: 505-272-2111
  • Fax:
Mailing address:
  • Phone: 858-243-0859
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2018-0077
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: