Provider Demographics
NPI:1679185938
Name:WILCOX, MATTHEW ZACHARY
Entity type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:ZACHARY
Last Name:WILCOX
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 GOSHEN RD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46808-1493
Mailing Address - Country:US
Mailing Address - Phone:574-385-3138
Mailing Address - Fax:
Practice Address - Street 1:2100 GOSHEN RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46808-1493
Practice Address - Country:US
Practice Address - Phone:574-385-3138
Practice Address - Fax:260-471-4263
Is Sole Proprietor?:No
Enumeration Date:2020-08-18
Last Update Date:2025-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10003629A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant