Provider Demographics
NPI:1184615650
Name:WILSON, SEAN PATRICK (MD)
Entity type:Individual
Prefix:DR
First Name:SEAN
Middle Name:PATRICK
Last Name:WILSON
Suffix:
Gender:M
Credentials:MD
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 878
Mailing Address - Street 2:
Mailing Address - City:SPRINGERVILLE
Mailing Address - State:AZ
Mailing Address - Zip Code:85938-0878
Mailing Address - Country:US
Mailing Address - Phone:928-333-5333
Mailing Address - Fax:928-333-5100
Practice Address - Street 1:606 N MAIN ST
Practice Address - Street 2:
Practice Address - City:EAGAR
Practice Address - State:AZ
Practice Address - Zip Code:85925-9813
Practice Address - Country:US
Practice Address - Phone:928-333-5333
Practice Address - Fax:928-333-5100
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-02
Last Update Date:2007-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ32794207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ880808Medicaid
AZZ102891Medicare PIN
AZ880808Medicaid