Healthcare Provider Details

I. General information

NPI: 1982978367
Provider Name (Legal Business Name): MICHELE MCNALLEY WILSON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/01/2012
Last Update Date: 05/21/2024
Certification Date: 05/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 S CENTER AVE
MERRILL WI
54452-3404
US

IV. Provider business mailing address

601 S CENTER AVE
MERRILL WI
54452-3404
US

V. Phone/Fax

Practice location:
  • Phone: 405-203-0749
  • Fax:
Mailing address:
  • Phone: 405-203-0749
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2066
License Number StateOK
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number3503-23
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: