Provider Demographics
NPI:1407673429
Name:WILSON, MIAH DAVIS (PA-C)
Entity type:Individual
Prefix:
First Name:MIAH
Middle Name:DAVIS
Last Name:WILSON
Suffix:
Gender:F
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 1:4949 RIDGEWOOD CT APT E
Mailing Address - Street 2:
Mailing Address - City:STOW
Mailing Address - State:OH
Mailing Address - Zip Code:44224-5354
Mailing Address - Country:US
Mailing Address - Phone:330-316-4799
Mailing Address - Fax:
Practice Address - Street 1:29017 CEDAR RD
Practice Address - Street 2:
Practice Address - City:LYNDHURST
Practice Address - State:OH
Practice Address - Zip Code:44124-4073
Practice Address - Country:US
Practice Address - Phone:440-461-7999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-23
Last Update Date:2024-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPP-000878082RX363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical