Provider Demographics
NPI:1891201604
Name:WILSON, MICHAEL PAUL (OTC)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:PAUL
Last Name:WILSON
Suffix:
Gender:M
Credentials:OTC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:324 GARDEN RD
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:PA
Mailing Address - Zip Code:19064-3505
Mailing Address - Country:US
Mailing Address - Phone:610-513-1001
Mailing Address - Fax:
Practice Address - Street 1:324 GARDEN RD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:PA
Practice Address - Zip Code:19064-3505
Practice Address - Country:US
Practice Address - Phone:610-513-1001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-18
Last Update Date:2017-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
12-0205156F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156F00000XEye and Vision Services ProvidersTechnician/Technologist