=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205351723
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | HYON SU WILSON ACNPC-AG
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/04/2017
-----------------------------------------------------
Last Update Date | 06/23/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9401 W THUNDERBIRD RD STE 180
-----------------------------------------------------
City | PEORIA
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85381-4210
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 623-516-8252
-----------------------------------------------------
Fax | 623-516-8253
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5281 N 99TH AVE STE 100
-----------------------------------------------------
City | GLENDALE
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85305-2209
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 623-516-8252
-----------------------------------------------------
Fax | 623-516-8253
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LA2100X
-----------------------------------------------------
Taxonomy Name | Acute Care Nurse Practitioner
-----------------------------------------------------
License Number | AP10376
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------