Basic Information
| Provider Information | |||||||||
| NPI: | 1831857168 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILMOT | ||||||||
| FirstName: | SEAN | ||||||||
| MiddleName: | RILEY | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 704 TIERRA ALEGRE CT | ||||||||
| Address2: | |||||||||
| City: | TIJERAS | ||||||||
| State: | NM | ||||||||
| PostalCode: | 870597844 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2533352335 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1100 CENTRAL AVE SE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871064930 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5057246124 | ||||||||
| FaxNumber: | 5057246125 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/03/2021 | ||||||||
| LastUpdateDate: | 12/03/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA2021-0113 | NM | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.