Provider Demographics
NPI:1902225766
Name:WILSON, NICHOLAS B (MD)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:B
Last Name:WILSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9323 PHOENIX VILLAGE PKWY
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63368-4281
Mailing Address - Country:US
Mailing Address - Phone:636-561-0871
Mailing Address - Fax:
Practice Address - Street 1:9323 PHOENIX VILLAGE PKWY
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:MO
Practice Address - Zip Code:63368-4281
Practice Address - Country:US
Practice Address - Phone:636-561-0871
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-09
Last Update Date:2023-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC82172207X00000X
ARE-13197207X00000X
MO2022030421207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery