Provider Demographics
NPI:1659699908
Name:WILSON, ANTHONY JOSEPH (MD)
Entity Type:Individual
Prefix:
First Name:ANTHONY
Middle Name:JOSEPH
Last Name:WILSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:137 PORTSMOUTH AVE
Mailing Address - Street 2:
Mailing Address - City:STRATHAM
Mailing Address - State:NH
Mailing Address - Zip Code:03885-2421
Mailing Address - Country:US
Mailing Address - Phone:603-775-7774
Mailing Address - Fax:
Practice Address - Street 1:137 PORTSMOUTH AVE
Practice Address - Street 2:
Practice Address - City:STRATHAM
Practice Address - State:NH
Practice Address - Zip Code:03885-2421
Practice Address - Country:US
Practice Address - Phone:603-775-7774
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-12
Last Update Date:2016-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH17483208200000X
PAMT197063390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery