Individual
KEVIN WILSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA-C
Contact information
Practice address
130 LINCOLN PLACE CT, BELLEVILLE, IL 62221-5884
(618) 257-2029
(618) 235-5371
Mailing address
4500 MEMORIAL DRIVE, MEMORIAL HOSPITAL CREDENTIALING DEPARTMENT, BELLEVILLE, IL 62226
(618) 257-4644
(618) 257-6946
Taxonomy
Speciality
Code
Description
License number
State
363AM0700X
Medical Physician Assistant
Primary
085-000488
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
085-000488
STATE LICENSE
IL
Enumeration date
08/12/2006
Last updated
03/21/2016
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