Provider Demographics
NPI:1063193126
Name:WILSON, SARA JANELLE (PA-C)
Entity type:Individual
Prefix:
First Name:SARA
Middle Name:JANELLE
Last Name:WILSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3200 VANTAGE WAY APT 111
Mailing Address - Street 2:
Mailing Address - City:CROZET
Mailing Address - State:VA
Mailing Address - Zip Code:22932-3197
Mailing Address - Country:US
Mailing Address - Phone:540-820-2061
Mailing Address - Fax:
Practice Address - Street 1:600 PETER JEFFERSON PKWY STE 310
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22911-8836
Practice Address - Country:US
Practice Address - Phone:434-977-0027
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-31
Last Update Date:2023-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110009445363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical