Healthcare Provider Details

I. General information

NPI: 1306806328
Provider Name (Legal Business Name): DENA MARIE WILSON P.A.-C
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 E 9TH ST NHCU
BONHAM TX
75418-4059
US

IV. Provider business mailing address

PO BOX 423
WHITEWRIGHT TX
75491-0423
US

V. Phone/Fax

Practice location:
  • Phone: 903-583-6500
  • Fax: 903-583-6625
Mailing address:
  • Phone: 903-583-6500
  • Fax: 903-583-6625

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA00741
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: