Provider Demographics
NPI:1669740361
Name:WILSON, RACHEL ANN (PA-C)
Entity type:Individual
Prefix:
First Name:RACHEL
Middle Name:ANN
Last Name:WILSON
Suffix:
Gender:F
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 1:300 W COUNTRY CLUB RD STE 210
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88201-5240
Mailing Address - Country:US
Mailing Address - Phone:575-622-2911
Mailing Address - Fax:575-622-2598
Practice Address - Street 1:300 W COUNTRY CLUB RD STE 210
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-5240
Practice Address - Country:US
Practice Address - Phone:575-622-2911
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-08
Last Update Date:2024-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA2022-0025363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant