Provider Demographics
NPI:1154159341
Name:WILSON, MITCHELL (CNP)
Entity type:Individual
Prefix:
First Name:MITCHELL
Middle Name:
Last Name:WILSON
Suffix:
Gender:M
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5885 HARRISON AVE STE 3500
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45248-1739
Mailing Address - Country:US
Mailing Address - Phone:513-922-9660
Mailing Address - Fax:513-347-2347
Practice Address - Street 1:5885 HARRISON AVE STE 3500
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45248-1739
Practice Address - Country:US
Practice Address - Phone:513-922-9660
Practice Address - Fax:513-347-2347
Is Sole Proprietor?:No
Enumeration Date:2024-07-22
Last Update Date:2024-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.0037106363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0059662Medicaid