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General NPI Number Information
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NPI Number | 1780675967
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Entity Type | Individual
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Provider Name | RUSSELL CARL WILSON P.A.-C, A.T.C.
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Gender | Male
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Dates
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Enumeration Date | 11/04/2005
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Last Update Date | 09/20/2022
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Provider Practice Location Address
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Address Line | 1125 RAINTREE CIR STE 100
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City | ALLEN
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State | TX
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Zip | 75013-5289
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Country | US
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Telephone | 972-727-9995
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Fax | 972-727-8350
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Provider Business Mailing Address
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Address Line | 1125 RAINTREE CIR STE 100
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City | ALLEN
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State | TX
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Zip | 75013-5289
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Country | US
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Telephone | 972-727-9995
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Fax | 972-727-8350
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 146L00000X
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Taxonomy Name | Paramedic
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License Number | 45448
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License Number State | TX
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Taxonomy #2
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | 020202111
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License Number State | NE
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Taxonomy #3
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | PA.0005767
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License Number State | CO
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Taxonomy #4
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 1092900
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License Number State | TX
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Taxonomy #5
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | PA06802
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License Number State | TX
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