Provider Demographics
NPI:1376500314
Name:WILSON, NATHAN E (MD)
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:E
Last Name:WILSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 MEDICAL CENTER DR
Mailing Address - Street 2:SUITE 201
Mailing Address - City:BIDDEFORD
Mailing Address - State:ME
Mailing Address - Zip Code:04005-9422
Mailing Address - Country:US
Mailing Address - Phone:207-282-9080
Mailing Address - Fax:207-282-9180
Practice Address - Street 1:30 W COLE RD
Practice Address - Street 2:
Practice Address - City:BIDDEFORD
Practice Address - State:ME
Practice Address - Zip Code:04005-9458
Practice Address - Country:US
Practice Address - Phone:207-282-3349
Practice Address - Fax:207-282-6099
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2012-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME012099207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME017203OtherANTHEM
ME1042108OtherAETNA
MEC66193OtherHARVARD PILGRIM
MEM10002801OtherCIGNA
ME277210099Medicaid
ME277210099Medicaid
MEMM049501Medicare PIN
ME1042108OtherAETNA