Provider Demographics
NPI:1407088206
Name:WILSON, MATTHEW ZACHARY (PA-C)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:ZACHARY
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 1:10451 CALLE PERDIZ NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87114-1312
Mailing Address - Country:US
Mailing Address - Phone:505-922-1419
Mailing Address - Fax:505-727-8086
Practice Address - Street 1:500 WALTER ST NE
Practice Address - Street 2:STE 309
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-2534
Practice Address - Country:US
Practice Address - Phone:505-727-8039
Practice Address - Fax:505-727-8086
Is Sole Proprietor?:No
Enumeration Date:2009-08-13
Last Update Date:2013-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA2009-0014363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant