Individual
SEAN M WILSON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA
Contact information
Practice address
1501 SAN PEDRO DR SE, ALBUQUERQUE, NM 87108-5153
(505) 265-1711
Mailing address
PO BOX 23974, SANTA FE, NM 87502-3974
(505) 463-5645
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
PA2005-0035
NM
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
10022311
LOVELACE
—
01
—
202005611
PRESBYTERIAN HEALTH PLANS
—
05
—
35377313
—
NM
01
—
QMYPR0072546
MOLINA
—
Enumeration date
12/06/2006
Last updated
12/07/2012
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