Provider Demographics
NPI:1639439805
Name:P NICK WILSON MD INC
Entity Type:Organization
Organization Name:P NICK WILSON MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:NICHOLAS
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-792-3914
Mailing Address - Street 1:PO BOX 3098
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90510-3098
Mailing Address - Country:US
Mailing Address - Phone:310-792-3914
Mailing Address - Fax:855-898-4055
Practice Address - Street 1:25500 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92562-5965
Practice Address - Country:US
Practice Address - Phone:951-696-6000
Practice Address - Fax:855-898-4055
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-22
Last Update Date:2012-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA615-07-2225207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADR543ZOtherMEDICARE PTAN