Provider Demographics
NPI:1366951519
Name:WILSON, PRISCILLA MARIE
Entity type:Individual
Prefix:MRS
First Name:PRISCILLA
Middle Name:MARIE
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3030 N CENTRAL AVE STE 1001
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85012-2716
Mailing Address - Country:US
Mailing Address - Phone:602-406-4786
Mailing Address - Fax:
Practice Address - Street 1:10005 E OSBORN RD
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85256-4019
Practice Address - Country:US
Practice Address - Phone:480-362-7400
Practice Address - Fax:480-362-5950
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-20
Last Update Date:2020-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP10609363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAP10609Medicaid