Provider Demographics
NPI:1982978367
Name:WILSON, MICHELE MCNALLEY (PA-C)
Entity type:Individual
Prefix:
First Name:MICHELE
Middle Name:MCNALLEY
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 1:601 S CENTER AVE
Mailing Address - Street 2:
Mailing Address - City:MERRILL
Mailing Address - State:WI
Mailing Address - Zip Code:54452-3404
Mailing Address - Country:US
Mailing Address - Phone:405-203-0749
Mailing Address - Fax:
Practice Address - Street 1:601 S CENTER AVE
Practice Address - Street 2:
Practice Address - City:MERRILL
Practice Address - State:WI
Practice Address - Zip Code:54452-3404
Practice Address - Country:US
Practice Address - Phone:405-203-0749
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-01
Last Update Date:2024-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK363A00000X
OKPA2066363A00000X
WI3503-23363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKPA2066OtherSTATE MEDICAL BOARD LICENSE
WI3503-23OtherSTATE OF WISCONSIN