Provider Demographics
NPI:1376776831
Name:WILSON, AMBER (PA-C)
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
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 1:25 N WINFIELD RD STE 424
Mailing Address - Street 2:
Mailing Address - City:WINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60190-1379
Mailing Address - Country:US
Mailing Address - Phone:630-933-4056
Mailing Address - Fax:630-933-4057
Practice Address - Street 1:25 N WINFIELD RD STE 424
Practice Address - Street 2:
Practice Address - City:WINFIELD
Practice Address - State:IL
Practice Address - Zip Code:60190-1379
Practice Address - Country:US
Practice Address - Phone:630-933-4056
Practice Address - Fax:630-933-4057
Is Sole Proprietor?:No
Enumeration Date:2009-09-01
Last Update Date:2021-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601005578363AM0700X
PAMA056675363AM0700X
IL085005692363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1376776831Medicaid
MI1417961137OtherBCBSM - BATTLE CREEK
MIN38550009Medicare PIN
MI1376776831Medicaid
MI0M74460396Medicare PIN