=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023843034
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MEGAN MARIE WILSON
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/09/2024
-----------------------------------------------------
Last Update Date | 09/09/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 323 SUNSET DR STE 2
-----------------------------------------------------
City | BUTLER
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 16001-4017
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 724-282-2730
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 402 EDGEWOOD DR
-----------------------------------------------------
City | SARVER
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 16055-9265
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 724-496-9299
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LW0102X
-----------------------------------------------------
Taxonomy Name | Women's Health Nurse Practitioner
-----------------------------------------------------
License Number | SP030187
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------