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Individual
MR. RUSSELL CARL WILSON
Active
Individual
MR. RUSSELL CARL WILSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
P.A.-C, A.T.C.
Taxonomy
Speciality
Code
Description
License number
State
146L00000X
Paramedic
45448
TX
2255A2300X
Athletic Trainer
020202111
NE
363A00000X
Physician Assistant
1092900
TX
363A00000X
Physician Assistant
PA.0005767
CO
363A00000X
Physician Assistant
Primary
PA06802
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
360930704
—
TX
01
—
8029NH
BCBSTX
TX
Enumeration date
11/04/2005
Last updated
09/20/2022
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