Provider Demographics
NPI:1639900129
Name:WESLEY G WILSON DO PA
Entity type:Organization
Organization Name:WESLEY G WILSON DO PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN /OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WESLEY
Authorized Official - Middle Name:GARRETT
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:469-720-4490
Mailing Address - Street 1:605 E BROAD ST
Mailing Address - Street 2:
Mailing Address - City:FORNEY
Mailing Address - State:TX
Mailing Address - Zip Code:75126-4116
Mailing Address - Country:US
Mailing Address - Phone:469-720-4490
Mailing Address - Fax:833-450-4889
Practice Address - Street 1:605 E BROAD ST
Practice Address - Street 2:
Practice Address - City:FORNEY
Practice Address - State:TX
Practice Address - Zip Code:75126-4116
Practice Address - Country:US
Practice Address - Phone:469-720-4490
Practice Address - Fax:833-450-4889
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-08
Last Update Date:2024-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty