Provider Demographics
NPI:1376192237
Name:WILSON, MATTHEW C
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:C
Last Name:WILSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3175 SIENNA DR S STE 105
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58104-8910
Mailing Address - Country:US
Mailing Address - Phone:701-451-9098
Mailing Address - Fax:701-451-9099
Practice Address - Street 1:3175 SIENNA DR S STE 105
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58104-8910
Practice Address - Country:US
Practice Address - Phone:701-451-9098
Practice Address - Fax:701-451-9099
Is Sole Proprietor?:No
Enumeration Date:2019-09-04
Last Update Date:2019-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1110111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor