Provider Demographics
NPI:1164118063
Name:WILSON, WILLIAM MARSHALL (NP)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:MARSHALL
Last Name:WILSON
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:371 ASTER TRCE
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30115-8428
Mailing Address - Country:US
Mailing Address - Phone:404-805-4283
Mailing Address - Fax:
Practice Address - Street 1:2000 HOWARD FARM DR STE 450
Practice Address - Street 2:
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30041-6085
Practice Address - Country:US
Practice Address - Phone:404-962-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-13
Last Update Date:2023-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN265440363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology