Basic Information
| Provider Information | |||||||||
| NPI: | 1417332081 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | ALAN | ||||||||
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| Credential: | AGACNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6550 FANNIN ST | ||||||||
| Address2: | SUITE 1601 | ||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770302717 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7134415141 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6550 FANNIN ST | ||||||||
| Address2: | SUITE 1601 | ||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770302717 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7134415141 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/24/2015 | ||||||||
| LastUpdateDate: | 01/17/2017 | ||||||||
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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 | 363LA2100X | AP128045 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
ID Information
| ID | Type | State | Issuer | Description | 8109NR | 01 | TX | BLUE CROSS BLUE SHIELD | OTHER | 8045NV | 01 | TX | BCBS | OTHER | 352267401 | 05 | TX | MEDICAID |