Provider Demographics
NPI:1760702161
Name:WILSON, ABBIGALE JOAN ELLYN (MD)
Entity Type:Individual
Prefix:
First Name:ABBIGALE
Middle Name:JOAN ELLYN
Last Name:WILSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:906 BUSINESS PARK DR
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49686-8683
Mailing Address - Country:US
Mailing Address - Phone:231-935-8750
Mailing Address - Fax:231-935-8749
Practice Address - Street 1:906 BUSINESS PARK DR
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49686-8683
Practice Address - Country:US
Practice Address - Phone:231-935-8750
Practice Address - Fax:231-935-8749
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-08
Last Update Date:2020-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301096549207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine