Provider Demographics
NPI:1396806402
Name:WILMORE, MICHAEL EUGENE II (PA-C)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:EUGENE
Last Name:WILMORE
Suffix:II
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 1:1330 NEW HAMPSHIRE AVE NW STE 121
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20036-6313
Mailing Address - Country:US
Mailing Address - Phone:202-463-0220
Mailing Address - Fax:
Practice Address - Street 1:1330 NEW HAMPSHIRE AVE NW STE 121
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20036-6313
Practice Address - Country:US
Practice Address - Phone:202-463-0220
Practice Address - Fax:202-463-0222
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2023-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAA10406363A00000X
DCPA030502363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant