Provider Demographics
NPI:1972547552
Name:WILSON, MATTHEW A (PA)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:A
Last Name:WILSON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:264 PLEASANT STREET
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NH
Mailing Address - Zip Code:03301-2551
Mailing Address - Country:US
Mailing Address - Phone:603-224-3368
Mailing Address - Fax:603-224-7815
Practice Address - Street 1:264 PLEASANT ST
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NH
Practice Address - Zip Code:03301-2551
Practice Address - Country:US
Practice Address - Phone:603-224-3368
Practice Address - Fax:603-224-7815
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2017-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPA714363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME297110099Medicaid
NH3099683Medicaid
MEAP1442Medicare ID - Type Unspecified
NH3099683Medicaid
S97782Medicare UPIN