Provider Demographics
NPI:1417332081
Name:WILSON, ALAN (AGACNP)
Entity Type:Individual
Prefix:
First Name:ALAN
Middle Name:
Last Name:WILSON
Suffix:
Gender:M
Credentials:AGACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6550 FANNIN ST
Mailing Address - Street 2:SUITE 1601
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030-2717
Mailing Address - Country:US
Mailing Address - Phone:713-441-5141
Mailing Address - Fax:
Practice Address - Street 1:6550 FANNIN ST
Practice Address - Street 2:SUITE 1601
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-2717
Practice Address - Country:US
Practice Address - Phone:713-441-5141
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-24
Last Update Date:2017-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP128045363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8109NROtherBLUE CROSS BLUE SHIELD
TX8045NVOtherBCBS
TX352267401Medicaid
TX352267401Medicaid