Provider Demographics
NPI:1780632711
Name:WILSON, MICHAEL CRAIG (DC)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:CRAIG
Last Name:WILSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:DR
Other - First Name:MICHAEL
Other - Middle Name:CRAIG
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DC
Mailing Address - Street 1:3161 W MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67213-2423
Mailing Address - Country:US
Mailing Address - Phone:316-942-9600
Mailing Address - Fax:316-351-6408
Practice Address - Street 1:3161 W MAPLE ST
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67213-2423
Practice Address - Country:US
Practice Address - Phone:316-942-9600
Practice Address - Fax:316-351-6408
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-04
Last Update Date:2020-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0104695111NS0005X, 111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS060855OtherBLUE CROSS/BLUE SHIELD