Provider Demographics
NPI:1730273673
Name:WILSON, MINDY SMITH (PA-C)
Entity type:Individual
Prefix:
First Name:MINDY
Middle Name:SMITH
Last Name:WILSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1404 TONEY DR SE
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35802-1231
Mailing Address - Country:US
Mailing Address - Phone:859-608-8890
Mailing Address - Fax:859-608-8890
Practice Address - Street 1:1404 TONEY DR SE
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35802-1231
Practice Address - Country:US
Practice Address - Phone:859-608-8890
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2011-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA996363A00000X, 363AM0700X
AL758363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY4000501OtherMEDICARE LAB GROUP
KY37903705OtherMEDICAID LAB GROUP
KY37903705OtherMEDICAID LAB GROUP
KY0623749Medicare PIN