Provider Demographics
NPI:1063684090
Name:WILSON, AMY M (PA-C)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:M
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:PO BOX 636461
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-6461
Mailing Address - Country:US
Mailing Address - Phone:440-988-1009
Mailing Address - Fax:440-988-1225
Practice Address - Street 1:319 W LORAIN ST
Practice Address - Street 2:
Practice Address - City:OBERLIN
Practice Address - State:OH
Practice Address - Zip Code:44074-1027
Practice Address - Country:US
Practice Address - Phone:440-775-1881
Practice Address - Fax:440-774-5707
Is Sole Proprietor?:No
Enumeration Date:2008-03-31
Last Update Date:2010-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.002742363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0236248Medicaid
OH9284951Medicare PIN
OH0236248Medicaid