Provider Demographics
NPI:1780675967
Name:WILSON, RUSSELL CARL (PA-C, ATC)
Entity Type:Individual
Prefix:MR
First Name:RUSSELL
Middle Name:CARL
Last Name:WILSON
Suffix:
Gender:M
Credentials:PA-C, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1125 RAINTREE CIR STE 100
Mailing Address - Street 2:
Mailing Address - City:ALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:75013-5289
Mailing Address - Country:US
Mailing Address - Phone:972-727-9995
Mailing Address - Fax:972-727-8350
Practice Address - Street 1:1125 RAINTREE CIR STE 100
Practice Address - Street 2:
Practice Address - City:ALLEN
Practice Address - State:TX
Practice Address - Zip Code:75013-5289
Practice Address - Country:US
Practice Address - Phone:972-727-9995
Practice Address - Fax:972-727-8350
Is Sole Proprietor?:No
Enumeration Date:2005-11-04
Last Update Date:2022-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX45448146L00000X
NE0202021112255A2300X
COPA.0005767363A00000X
TX1092900363A00000X
TXPA06802363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No146L00000XEmergency Medical Service ProvidersEmergency Medical Technician, Paramedic
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX360930704Medicaid
TX8029NHOtherBCBSTX