Provider Demographics
NPI:1174683205
Name:WILSON, MICHELLE ROSS (APRN)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:ROSS
Last Name:WILSON
Suffix:
Gender:F
Credentials:APRN
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 497
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:AR
Mailing Address - Zip Code:72006-0497
Mailing Address - Country:US
Mailing Address - Phone:870-347-2534
Mailing Address - Fax:870-301-2092
Practice Address - Street 1:2200 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42003-3256
Practice Address - Country:US
Practice Address - Phone:870-347-2534
Practice Address - Fax:870-301-2092
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-11
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3003898363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100077530Medicaid
KYP00754207Medicare PIN
KYP73262Medicare UPIN
KY7100077530Medicaid
KY0351612Medicare PIN