Provider Demographics
NPI:1427056712
Name:WILSON, JOEL L (PAC)
Entity type:Individual
Prefix:
First Name:JOEL
Middle Name:L
Last Name:WILSON
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3100 MAIN ST STE 705
Mailing Address - Street 2:
Mailing Address - City:MAUMEE
Mailing Address - State:OH
Mailing Address - Zip Code:43537-9867
Mailing Address - Country:US
Mailing Address - Phone:419-383-2777
Mailing Address - Fax:419-383-2738
Practice Address - Street 1:3100 MAIN ST STE 705
Practice Address - Street 2:
Practice Address - City:MAUMEE
Practice Address - State:OH
Practice Address - Zip Code:43537-9867
Practice Address - Country:US
Practice Address - Phone:419-383-2777
Practice Address - Fax:419-383-2738
Is Sole Proprietor?:No
Enumeration Date:2005-07-11
Last Update Date:2023-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50-00-1912363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHPA19962Medicare PIN
OHWIPA19961Medicare PIN
P73102Medicare UPIN