| Doctor Name: | NICHOLAS RICHARD WILSON |
| NPI Number: | 1407871262 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | PA-C |
| License Number: | 5601005306 |
| Business Practice Address: | 8765 Lewis Ave Temperance, MI - 481829583 |
| Business Phone Number: | 7348473802 |
| Business Fax Number: | |
| Mailing Address: | 8765 Lewis Ave, TEMPERANCE |
| State: | MI |
| Postal Code: | 481829583 |
| Phone Number: | 7348473802 |
| Fax Number: | |
| NPI Enumeration Date: | 07/13/2006 |
| NPI Last Update Date: | 02/26/2014 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 363AM0700X |
| License Number: | 5601005306 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | MI |
| Taxonomy Type: | Physician Assistants & Advanced Practice Nursing Providers |
| Taxonomy Classification: | Physician Assistant |
| Taxonomy Specialization: | Medical |
| Taxonomy Definition: | |