Provider Demographics
NPI:1043214968
Name:WILSON, MELANIE L (PA-C)
Entity Type:Individual
Prefix:MS
First Name:MELANIE
Middle Name:L
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 1:200 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:SPENCER
Mailing Address - State:WV
Mailing Address - Zip Code:25276-1050
Mailing Address - Country:US
Mailing Address - Phone:304-927-6822
Mailing Address - Fax:304-927-6873
Practice Address - Street 1:200 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:SPENCER
Practice Address - State:WV
Practice Address - Zip Code:25276-1050
Practice Address - Country:US
Practice Address - Phone:304-927-6822
Practice Address - Fax:304-927-6873
Is Sole Proprietor?:No
Enumeration Date:2005-06-09
Last Update Date:2023-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV669363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810000833Medicaid
WV3810000833Medicaid