Healthcare Provider Details

I. General information

NPI: 1659933505
Provider Name (Legal Business Name): MITCHELL WILSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2019
Last Update Date: 07/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

47 NEW SCOTLAND AVENUE, DEPT. OF INTERNAL MEDICINE
ALBANY NY
12208
US

IV. Provider business mailing address

47 NEW SCOTLAND AVENUE, DEPT. OF INTERNAL MEDICINE
ALBANY NY
12208
US

V. Phone/Fax

Practice location:
  • Phone: 518-262-5735
  • Fax:
Mailing address:
  • Phone: 518-262-5735
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number64246
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: