Provider Demographics
NPI:1639537707
Name:WILSON, RALPH EDWIN JR (PA-C)
Entity Type:Individual
Prefix:MR
First Name:RALPH
Middle Name:EDWIN
Last Name:WILSON
Suffix:JR
Gender:M
Credentials:PA-C
Other - Prefix:MR
Other - First Name:ED
Other - Middle Name:
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 5105
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-5100
Mailing Address - Country:US
Mailing Address - Phone:919-220-5255
Mailing Address - Fax:
Practice Address - Street 1:100 KELLIE DRIVE
Practice Address - Street 2:
Practice Address - City:SMITHFIELD
Practice Address - State:NC
Practice Address - Zip Code:27577
Practice Address - Country:US
Practice Address - Phone:919-934-1094
Practice Address - Fax:919-313-1276
Is Sole Proprietor?:No
Enumeration Date:2016-02-04
Last Update Date:2022-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-06282363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant