Provider Demographics
NPI:1861567661
Name:WILSON, MICHAEL GRANT (MD, MBA)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:GRANT
Last Name:WILSON
Suffix:
Gender:M
Credentials:MD, MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 BRENTWOOD DR. SUITE A
Mailing Address - Street 2:CAYUGA MEDICAL ASSOCIATES
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850
Mailing Address - Country:US
Mailing Address - Phone:607-272-7000
Mailing Address - Fax:
Practice Address - Street 1:77 NELSON ST
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:NY
Practice Address - Zip Code:13021-1944
Practice Address - Country:US
Practice Address - Phone:315-255-7011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2022-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY263199207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery