Provider Demographics
NPI:1518114800
Name:WILSON, ADAM RICHARD (PA-C)
Entity Type:Individual
Prefix:
First Name:ADAM
Middle Name:RICHARD
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 1:2935 HEALTH PKWY
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:MI
Mailing Address - Zip Code:48858-8931
Mailing Address - Country:US
Mailing Address - Phone:989-772-1609
Mailing Address - Fax:989-773-6279
Practice Address - Street 1:2935 HEALTH PKWY
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:MI
Practice Address - Zip Code:48858-8931
Practice Address - Country:US
Practice Address - Phone:989-772-1609
Practice Address - Fax:989-773-6279
Is Sole Proprietor?:No
Enumeration Date:2008-08-19
Last Update Date:2024-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601005338363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5601005338OtherSTATE LICENSE