Provider Demographics
NPI:1467556787
Name:WILSON, MELANIE DECOCK (PA)
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:DECOCK
Last Name:WILSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2900 S 25TH ST STE B2
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:IA
Mailing Address - Zip Code:52732-7250
Mailing Address - Country:US
Mailing Address - Phone:563-519-8120
Mailing Address - Fax:
Practice Address - Street 1:2900 S 25TH ST STE B2
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:IA
Practice Address - Zip Code:52732-7250
Practice Address - Country:US
Practice Address - Phone:563-519-8120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-08
Last Update Date:2020-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1333363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCP67098Medicare UPIN