MEDICARE: PHILSHANWA WILSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	172V00000X	Community Health Worker

General Provider Information

NPI Number	:	1326907973
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PHILSHANWA WILSON

Provider Business Mailing Address
First Line	:	10 PETERBORO ST
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48201-2722
Country	:	US
Telephone Number	:	313-989-3437
Fax Number	:

Provider Business Practice Location Address
First Line	:	10 PETERBORO ST
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48201-2722
Country	:	US
Telephone Number	:	313-989-3437
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/20/2026
Last Update Date	:	01/20/2026

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Directions to “ PHILSHANWA WILSON ” Practice Location

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