MEDICARE: MR. WELTON WAYNE WILSON P.A.

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	363A00000X	Physician Assistant	1062036

General Provider Information

NPI Number	:	1568646644
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. WELTON WAYNE WILSON P.A.

Provider Business Mailing Address
First Line	:	19073 I 45 S STE 145
Second Line	:	SYNERGENX HEALTH
City	:	SHENANDOAH
State	:	TX
Zip	:	77385-8744
Country	:	US
Telephone Number	:	281-362-5580
Fax Number	:

Provider Business Practice Location Address
First Line	:	19073 I 45 S STE 145
Second Line	:	SYNERGENX HEALTH
City	:	SHENANDOAH
State	:	TX
Zip	:	77385-8744
Country	:	US
Telephone Number	:	281-362-5580
Fax Number	:

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

Provider Enumeration Date	:	12/24/2007
Last Update Date	:	10/16/2020

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