Provider Demographics
NPI:1568646644
Name:WILSON, WELTON WAYNE (PA)
Entity Type:Individual
Prefix:MR
First Name:WELTON
Middle Name:WAYNE
Last Name:WILSON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
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Mailing Address - Street 1:19073 I 45 S STE 145
Mailing Address - Street 2:SYNERGENX HEALTH
Mailing Address - City:SHENANDOAH
Mailing Address - State:TX
Mailing Address - Zip Code:77385-8744
Mailing Address - Country:US
Mailing Address - Phone:281-362-5580
Mailing Address - Fax:
Practice Address - Street 1:19073 I 45 S STE 145
Practice Address - Street 2:SYNERGENX HEALTH
Practice Address - City:SHENANDOAH
Practice Address - State:TX
Practice Address - Zip Code:77385-8744
Practice Address - Country:US
Practice Address - Phone:281-362-5580
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-24
Last Update Date:2020-10-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
1062036363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant