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NPI Code Detail

MEDICARE: NICHOLAS RICHARD WILSON PA-C

MEDICARE: NICHOLAS RICHARD WILSON PA-C
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
1363AM0700XMedical Physician Assistant5601005306MI

General Provider Information

NPI Number : 1407871262
Entity Type Code : Individual
Provider Name (Legal Business Name) : NICHOLAS RICHARD WILSON PA-C
Provider Business Mailing Address
First Line : 8765 LEWIS AVE
Second Line :
City : TEMPERANCE
State : MI
Zip : 48182-9583
Country : US
Telephone Number : 734-847-3802
Fax Number :
Provider Business Practice Location Address
First Line : 8765 LEWIS AVE
Second Line :
City : TEMPERANCE
State : MI
Zip : 48182-9583
Country : US
Telephone Number : 734-847-3802
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/13/2006
Last Update Date : 02/26/2014

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Directions to “ NICHOLAS RICHARD WILSON PA-C” Practice Location

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