Provider Demographics
NPI:1386703478
Name:WILSON, SEAN M (PA)
Entity type:Individual
Prefix:
First Name:SEAN
Middle Name:M
Last Name:WILSON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 23974
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87502-3974
Mailing Address - Country:US
Mailing Address - Phone:505-463-5645
Mailing Address - Fax:
Practice Address - Street 1:1501 SAN PEDRO DR SE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87108-5153
Practice Address - Country:US
Practice Address - Phone:505-265-1711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-06
Last Update Date:2012-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA2005-0035363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
202005611OtherPRESBYTERIAN HEALTH PLANS
10022311OtherLOVELACE
QMYPR0072546OtherMOLINA
NM35377313Medicaid
NM345702201Medicare PIN