Provider Demographics
NPI:1912419276
Name:WILSON, ALIX MACKENZIE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:ALIX
Middle Name:MACKENZIE
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 1:2207 BRIDGEPORT WAY
Mailing Address - Street 2:
Mailing Address - City:MARTINEZ
Mailing Address - State:CA
Mailing Address - Zip Code:94553-6711
Mailing Address - Country:US
Mailing Address - Phone:203-570-0111
Mailing Address - Fax:
Practice Address - Street 1:747 52ND ST
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-1809
Practice Address - Country:US
Practice Address - Phone:203-570-0111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-26
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA550252080S0010X
CAPA55025363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No2080S0010XAllopathic & Osteopathic PhysiciansPediatricsSports Medicine
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant