Provider Demographics
NPI:1295045425
Name:WILSON, MATTHEW TODD (ACNS-BC, APN)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:TODD
Last Name:WILSON
Suffix:
Gender:M
Credentials:ACNS-BC, APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 N 3RD ST
Mailing Address - Street 2:
Mailing Address - City:WYOMING
Mailing Address - State:IL
Mailing Address - Zip Code:61491-1223
Mailing Address - Country:US
Mailing Address - Phone:309-606-3152
Mailing Address - Fax:
Practice Address - Street 1:530 NE GLEN OAK AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61637-0001
Practice Address - Country:US
Practice Address - Phone:309-655-2000
Practice Address - Fax:309-655-7869
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-21
Last Update Date:2010-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.008422364SA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult Health