Provider Demographics
NPI:1679392211
Name:WILSON-MACK, ASIA
Entity type:Individual
Prefix:
First Name:ASIA
Middle Name:
Last Name:WILSON-MACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:418 BROADWAY STE 4286
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12207-2922
Mailing Address - Country:US
Mailing Address - Phone:929-746-6119
Mailing Address - Fax:
Practice Address - Street 1:418 BROADWAY STE 4286
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12207-2922
Practice Address - Country:US
Practice Address - Phone:929-746-6119
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-09
Last Update Date:2024-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY608193163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163W00000XNursing Service ProvidersRegistered NurseGroup - Multi-Specialty