Provider Demographics
NPI:1467085746
Name:WILSON, MERON (PA)
Entity Type:Individual
Prefix:
First Name:MERON
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:MERON
Other - Middle Name:
Other - Last Name:GIZAW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:806 HAY ST
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28305-5312
Mailing Address - Country:US
Mailing Address - Phone:910-860-7008
Mailing Address - Fax:910-824-7593
Practice Address - Street 1:806 HAY ST
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28305-5312
Practice Address - Country:US
Practice Address - Phone:910-860-7008
Practice Address - Fax:910-824-7593
Is Sole Proprietor?:No
Enumeration Date:2020-02-15
Last Update Date:2021-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AM0700X
NC0010-09503363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical