Provider Demographics
NPI:1326204496
Name:WILSON, MATTHEW F (PA-C)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:F
Last Name:WILSON
Suffix:
Gender:M
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 1:4537 BUCHANAN AVE SW
Mailing Address - Street 2:
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49548-4168
Mailing Address - Country:US
Mailing Address - Phone:248-755-1873
Mailing Address - Fax:
Practice Address - Street 1:620 BYRON RD
Practice Address - Street 2:
Practice Address - City:HOWELL
Practice Address - State:MI
Practice Address - Zip Code:48843-1002
Practice Address - Country:US
Practice Address - Phone:517-545-6318
Practice Address - Fax:517-545-1942
Is Sole Proprietor?:No
Enumeration Date:2008-07-29
Last Update Date:2008-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601005303363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
80022907OtherCREDENTIALING