Provider Demographics
NPI:1386727006
Name:WILSON, NATHAN A (MD)
Entity type:Individual
Prefix:DR
First Name:NATHAN
Middle Name:A
Last Name:WILSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6531 RIVER BLUFF TRL
Mailing Address - Street 2:
Mailing Address - City:MARTINEZ
Mailing Address - State:GA
Mailing Address - Zip Code:30907-3317
Mailing Address - Country:US
Mailing Address - Phone:706-831-5834
Mailing Address - Fax:
Practice Address - Street 1:3485 MIKE PADGETT HWY
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30906-3815
Practice Address - Country:US
Practice Address - Phone:706-771-7843
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2020-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA057203208000000X
GA57203208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA597935080AMedicaid