Provider Demographics
NPI:1275007544
Name:WILCOX, ANISHA A (NP)
Entity Type:Individual
Prefix:
First Name:ANISHA
Middle Name:A
Last Name:WILCOX
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27461 SELKIRK ST
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48076-5146
Mailing Address - Country:US
Mailing Address - Phone:313-231-1826
Mailing Address - Fax:
Practice Address - Street 1:22200 W 11 MILE RD
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48037-3451
Practice Address - Country:US
Practice Address - Phone:313-231-1826
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-19
Last Update Date:2020-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIF01190098363LF0000X
MI1275007544363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4704267019Medicaid
MIF01190098Medicaid