Healthcare Provider Details

I. General information

NPI: 1770782997
Provider Name (Legal Business Name): PAUL THOMAS WILSON P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2007
Last Update Date: 07/17/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

230 NORTH RD LEXINGTON CTR FOR RECOVERY-MMTP
POUGHKEEPSIE NY
12601-1328
US

IV. Provider business mailing address

99 HOOF PRINT RD
MILLBROOK NY
12545-6001
US

V. Phone/Fax

Practice location:
  • Phone: 845-486-2850
  • Fax: 845-486-2770
Mailing address:
  • Phone: 845-677-8248
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number002282-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: