Provider Demographics
NPI:1336837236
Name:ROMULUS, WILSON
Entity Type:Individual
Prefix:
First Name:WILSON
Middle Name:
Last Name:ROMULUS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27026 SUTHERLAND ST
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48076-3562
Mailing Address - Country:US
Mailing Address - Phone:248-761-6497
Mailing Address - Fax:
Practice Address - Street 1:251 N MAIN ST
Practice Address - Street 2:
Practice Address - City:CEDARVILLE
Practice Address - State:OH
Practice Address - Zip Code:45314-8501
Practice Address - Country:US
Practice Address - Phone:193-776-6770
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-27
Last Update Date:2023-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant