Provider Demographics
NPI:1538547427
Name:WILSON, PETER
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:WILSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:807 ORCHARD PEAK CT
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77062-2167
Mailing Address - Country:US
Mailing Address - Phone:281-218-0642
Mailing Address - Fax:
Practice Address - Street 1:807 ORCHARD PEAK CT
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77062-2167
Practice Address - Country:US
Practice Address - Phone:281-218-0642
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-11
Last Update Date:2015-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP127840363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care