Provider Demographics
NPI:1962545343
Name:WILSON, MATTHEW H (PMH-NP)
Entity type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:H
Last Name:WILSON
Suffix:
Gender:M
Credentials:PMH-NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:12 BOLDUC AVE
Mailing Address - Street 2:
Mailing Address - City:FORT KENT
Mailing Address - State:ME
Mailing Address - Zip Code:04743-1602
Mailing Address - Country:US
Mailing Address - Phone:207-834-3971
Mailing Address - Fax:207-834-3837
Practice Address - Street 1:12 BOLDUC AVE
Practice Address - Street 2:
Practice Address - City:FORT KENT
Practice Address - State:ME
Practice Address - Zip Code:04743-1602
Practice Address - Country:US
Practice Address - Phone:207-834-3971
Practice Address - Fax:207-834-3837
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-15
Last Update Date:2022-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MER050669363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health