MEDICARE: PRISHAE 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	390200000X	Student in an Organized Health Care Education/Training Program	4351055699	MI

General Provider Information

NPI Number	:	1538832167
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PRISHAE WILSON

Provider Business Mailing Address
First Line	:	1500 E MEDICAL CENTER DR
Second Line	:
City	:	ANN ARBOR
State	:	MI
Zip	:	48109-5312
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1500 E MEDICAL CENTER DR SPC 5312
Second Line	:
City	:	ANN ARBOR
State	:	MI
Zip	:	48109-5312
Country	:	US
Telephone Number	:	734-736-9178
Fax Number	:

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

Provider Enumeration Date	:	07/29/2021
Last Update Date	:	04/12/2026

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Directions to “ PRISHAE WILSON ” Practice Location

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