Basic Information
| Provider Information | |||||||||
| NPI: | 1407088206 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | ZACHARY | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10451 CALLE PERDIZ NW | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871141312 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5059221419 | ||||||||
| FaxNumber: | 5057278086 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 WALTER ST NE | ||||||||
| Address2: | STE 309 | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871022534 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5057278039 | ||||||||
| FaxNumber: | 5057278086 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/13/2009 | ||||||||
| LastUpdateDate: | 05/06/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA2009-0014 | NM | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.