Provider Demographics
NPI:1124665526
Name:WILSON, PRISCILLA
Entity type:Individual
Prefix:
First Name:PRISCILLA
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 TRADEWINDS BLVD STE B
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:TX
Mailing Address - Zip Code:79706-3166
Mailing Address - Country:US
Mailing Address - Phone:432-618-6772
Mailing Address - Fax:432-618-6775
Practice Address - Street 1:701 TRADEWINDS BLVD STE B
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:TX
Practice Address - Zip Code:79706-3166
Practice Address - Country:US
Practice Address - Phone:432-618-6772
Practice Address - Fax:432-618-6775
Is Sole Proprietor?:No
Enumeration Date:2019-12-04
Last Update Date:2019-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX8870862086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery