Healthcare Provider Details

I. General information

NPI: 1841177623
Provider Name (Legal Business Name): KEVIN A. WILSON CRPA-P
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2025
Last Update Date: 08/21/2025
Certification Date: 08/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 WHITESBORO ST
UTICA NY
13502-3015
US

IV. Provider business mailing address

500 WHITESBORO ST
UTICA NY
13502-3015
US

V. Phone/Fax

Practice location:
  • Phone: 315-607-2115
  • Fax: 315-607-2115
Mailing address:
  • Phone: 315-724-5168
  • Fax: 315-724-6582

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberCRPA-P-8736
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: