Provider Demographics
NPI:1063424984
Name:WILSON, KEVIN (PA-C)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:WILSON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4500 MEMORIAL DRIVE
Mailing Address - Street 2:MEMORIAL HOSPITAL CREDENTIALING DEPARTMENT
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62226
Mailing Address - Country:US
Mailing Address - Phone:618-257-4644
Mailing Address - Fax:618-257-6946
Practice Address - Street 1:130 LINCOLN PLACE CT
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62221-5884
Practice Address - Country:US
Practice Address - Phone:618-257-2029
Practice Address - Fax:618-235-5371
Is Sole Proprietor?:No
Enumeration Date:2006-08-12
Last Update Date:2016-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085-000488363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL085-000488OtherSTATE LICENSE