Provider Demographics
NPI:1760779904
Name:WILSON, MICAH JAMES (NP)
Entity Type:Individual
Prefix:
First Name:MICAH
Middle Name:JAMES
Last Name:WILSON
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1050 SW 3RD AVE
Mailing Address - Street 2:STE 3200
Mailing Address - City:ONTARIO
Mailing Address - State:OR
Mailing Address - Zip Code:97914-2193
Mailing Address - Country:US
Mailing Address - Phone:541-881-7370
Mailing Address - Fax:541-881-7379
Practice Address - Street 1:1050 SW 3RD AVE
Practice Address - Street 2:STE 3200
Practice Address - City:ONTARIO
Practice Address - State:OR
Practice Address - Zip Code:97914-2193
Practice Address - Country:US
Practice Address - Phone:541-881-7370
Practice Address - Fax:541-881-7379
Is Sole Proprietor?:No
Enumeration Date:2011-07-08
Last Update Date:2011-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201150063NP363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner