Provider Demographics
NPI:1407871262
Name:WILSON, NICHOLAS RICHARD (PA-C)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:RICHARD
Last Name:WILSON
Suffix:
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 1:8765 LEWIS AVE
Mailing Address - Street 2:
Mailing Address - City:TEMPERANCE
Mailing Address - State:MI
Mailing Address - Zip Code:48182-9583
Mailing Address - Country:US
Mailing Address - Phone:734-847-3802
Mailing Address - Fax:
Practice Address - Street 1:8765 LEWIS AVE
Practice Address - Street 2:
Practice Address - City:TEMPERANCE
Practice Address - State:MI
Practice Address - Zip Code:48182-9583
Practice Address - Country:US
Practice Address - Phone:734-847-3802
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2014-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601005306363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILS87612Medicare UPIN