Healthcare Provider Details

I. General information

NPI: 1427056712
Provider Name (Legal Business Name): JOEL L WILSON PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2005
Last Update Date: 09/15/2023
Certification Date: 09/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3100 MAIN ST STE 705
MAUMEE OH
43537-9867
US

IV. Provider business mailing address

3100 MAIN ST STE 705
MAUMEE OH
43537-9867
US

V. Phone/Fax

Practice location:
  • Phone: 419-383-2777
  • Fax: 419-383-2738
Mailing address:
  • Phone: 419-383-2777
  • Fax: 419-383-2738

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number50-00-1912
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: