Provider Demographics
NPI:1871889618
Name:WILSON, CREIGHTON GERALD JR (NP-C)
Entity type:Individual
Prefix:MR
First Name:CREIGHTON
Middle Name:GERALD
Last Name:WILSON
Suffix:JR
Gender:M
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1721 BIRMINGHAM RD STE 202
Mailing Address - Street 2:
Mailing Address - City:COLLEGE STATION
Mailing Address - State:TX
Mailing Address - Zip Code:77845-4081
Mailing Address - Country:US
Mailing Address - Phone:979-446-0373
Mailing Address - Fax:
Practice Address - Street 1:1721 BIRMINGHAM RD STE 202
Practice Address - Street 2:
Practice Address - City:COLLEGE STATION
Practice Address - State:TX
Practice Address - Zip Code:77845-4081
Practice Address - Country:US
Practice Address - Phone:979-446-0373
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-21
Last Update Date:2021-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX737316363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner