Provider Demographics
NPI:1790980381
Name:WILSON, KEVIN WILLIAM (MD)
Entity Type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:WILLIAM
Last Name:WILSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1700 OLD GATESBURG RD STE 200
Mailing Address - Street 2:
Mailing Address - City:STATE COLLEGE
Mailing Address - State:PA
Mailing Address - Zip Code:16803-2276
Mailing Address - Country:US
Mailing Address - Phone:814-237-4321
Mailing Address - Fax:814-235-0484
Practice Address - Street 1:1700 OLD GATESBURG RD STE 200
Practice Address - Street 2:
Practice Address - City:STATE COLLEGE
Practice Address - State:PA
Practice Address - Zip Code:16803-2276
Practice Address - Country:US
Practice Address - Phone:814-237-4321
Practice Address - Fax:814-235-0484
Is Sole Proprietor?:No
Enumeration Date:2007-06-15
Last Update Date:2019-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD468320207XX0005X, 207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine