Basic Information
| Provider Information | |||||||||
| NPI: | 1124783584 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | PATRICK | ||||||||
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| Credential: | PHYSICIAN ASSISTANT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4230 CAMP HORNER RD | ||||||||
| Address2: | |||||||||
| City: | VESTAVIA | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352433043 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2052403760 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2211 LOMAS BLVD NE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871062719 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052720621 | ||||||||
| FaxNumber: | 5059252487 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2021 | ||||||||
| LastUpdateDate: | 11/03/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA.1801 | AL | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | PA2021-0097 | NM | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.