Provider Demographics
NPI:1942399522
Name:WILSON, SCOTT W (PA-C)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:W
Last Name:WILSON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:702 PLATINUM AVE
Mailing Address - Street 2:
Mailing Address - City:CODY
Mailing Address - State:WY
Mailing Address - Zip Code:82414-3423
Mailing Address - Country:US
Mailing Address - Phone:307-578-1985
Mailing Address - Fax:307-578-1938
Practice Address - Street 1:450 MOUNTAIN VIEW ST
Practice Address - Street 2:
Practice Address - City:POWELL
Practice Address - State:WY
Practice Address - Zip Code:82435-2212
Practice Address - Country:US
Practice Address - Phone:307-754-7257
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2021-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY325363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WYP75928Medicare UPIN