MEDICARE: LEAH ANN 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	PA01016	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	8Y8467	OTHER	TX	BCBS OF TX

General Provider Information

NPI Number	:	1669634150
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LEAH ANN WILSON P.A.

Provider Business Mailing Address
First Line	:	929 HILLTOP DR
Second Line	:
City	:	WEATHERFORD
State	:	TX
Zip	:	76086-5845
Country	:	US
Telephone Number	:	817-599-7576
Fax Number	:	817-596-7901

Provider Business Practice Location Address
First Line	:	929 HILLTOP DR
Second Line	:
City	:	WEATHERFORD
State	:	TX
Zip	:	76086-5845
Country	:	US
Telephone Number	:	817-599-7576
Fax Number	:	817-596-7901

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

Provider Enumeration Date	:	06/26/2008
Last Update Date	:	09/07/2016

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