Provider Demographics
NPI:1144658055
Name:WILSON, MICHAEL J (PAC)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:WILSON
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9101
Mailing Address - Street 2:
Mailing Address - City:COPPELL
Mailing Address - State:TX
Mailing Address - Zip Code:75019-9494
Mailing Address - Country:US
Mailing Address - Phone:972-745-7500
Mailing Address - Fax:
Practice Address - Street 1:39769 LBJ FWY
Practice Address - Street 2:CARE NOW MEDICAL CENTER
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75237-3560
Practice Address - Country:US
Practice Address - Phone:972-780-0802
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-10-31
Last Update Date:2014-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA08779363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant