Provider Demographics
NPI:1871539973
Name:WILSON, MICHAEL A (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:A
Last Name:WILSON
Suffix:
Gender:M
Credentials:MD
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 3158
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3158
Mailing Address - Country:US
Mailing Address - Phone:503-215-6494
Mailing Address - Fax:503-215-6644
Practice Address - Street 1:9427 SW BARNES RD
Practice Address - Street 2:STE 498
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-6652
Practice Address - Country:US
Practice Address - Phone:503-216-0900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD15370207RC0000X, 207RI0011X
WAMD00049331207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAP00909394OtherRR MEDICARE
ORP00848627OtherRR MEDICARE
OR202895Medicaid
WAP00909394OtherRR MEDICARE
OR202895Medicaid
ORR156587Medicare PIN
ORR157907Medicare PIN
ORR08000406XMedicare PIN
WAG8921811Medicare PIN
ORR167184Medicare PIN
ORA16587Medicare UPIN
ORR158682Medicare PIN
ORR159885Medicare PIN
ORR154531Medicare PIN