Provider Demographics
NPI:1982732301
Name:WILSON, EDITH E (NP)
Entity Type:Individual
Prefix:
First Name:EDITH
Middle Name:E
Last Name:WILSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 PINE RIDGE TER
Mailing Address - Street 2:
Mailing Address - City:CHEEKTOWAGA
Mailing Address - State:NY
Mailing Address - Zip Code:14225-3923
Mailing Address - Country:US
Mailing Address - Phone:716-830-0373
Mailing Address - Fax:716-931-5100
Practice Address - Street 1:5949 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:NY
Practice Address - Zip Code:14086-9523
Practice Address - Country:US
Practice Address - Phone:716-684-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-28
Last Update Date:2015-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY303729363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYIA0663Medicare ID - Type UnspecifiedPROVIDER ID
NYQ35346Medicare UPIN