Provider Demographics
NPI:1053359885
Name:WILSON, INYANG E (PA)
Entity type:Individual
Prefix:MR
First Name:INYANG
Middle Name:E
Last Name:WILSON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 921
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:TX
Mailing Address - Zip Code:77545-0921
Mailing Address - Country:US
Mailing Address - Phone:979-871-9453
Mailing Address - Fax:979-871-9429
Practice Address - Street 1:606 N GULF BLVD
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:TX
Practice Address - Zip Code:77541-3902
Practice Address - Country:US
Practice Address - Phone:979-871-9354
Practice Address - Fax:979-871-9429
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-03
Last Update Date:2013-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA00933363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8A5164Medicare PIN
TXP14150Medicare UPIN