Provider Demographics
NPI:1174710404
Name:WILTON, MATTHEW JV (PA-C)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:JV
Last Name:WILTON
Suffix:
Gender:M
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 1:1850 WHITES RD
Mailing Address - Street 2:SUITE 3
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49008-4801
Mailing Address - Country:US
Mailing Address - Phone:269-343-3900
Mailing Address - Fax:269-343-5640
Practice Address - Street 1:1850 WHITES RD
Practice Address - Street 2:SUITE 3
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49008-4801
Practice Address - Country:US
Practice Address - Phone:269-343-3900
Practice Address - Fax:269-343-5640
Is Sole Proprietor?:No
Enumeration Date:2007-10-01
Last Update Date:2014-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601005140363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIM79650047Medicare PIN
MIC96159083Medicare PIN
MIP08090104Medicare PIN