Provider Demographics
NPI:1073782140
Name:WILSON, PAUL JOSEPH (DC)
Entity Type:Individual
Prefix:DR
First Name:PAUL
Middle Name:JOSEPH
Last Name:WILSON
Suffix:
Gender:M
Credentials:DC
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 215
Mailing Address - Street 2:
Mailing Address - City:HORNER
Mailing Address - State:WV
Mailing Address - Zip Code:26372-0215
Mailing Address - Country:US
Mailing Address - Phone:304-517-1355
Mailing Address - Fax:304-517-1356
Practice Address - Street 1:2828 OLD ROUTE 33
Practice Address - Street 2:
Practice Address - City:HORNER
Practice Address - State:WV
Practice Address - Zip Code:26372-9705
Practice Address - Country:US
Practice Address - Phone:304-517-1355
Practice Address - Fax:304-517-1356
Is Sole Proprietor?:No
Enumeration Date:2008-02-22
Last Update Date:2008-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV780111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WVWI4119841Medicare UPIN
WVMC9338391Medicare PIN