Provider Demographics
NPI:1073536397
Name:WILSON, SARAH E (PA)
Entity type:Individual
Prefix:
First Name:SARAH
Middle Name:E
Last Name:WILSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 4699
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47903-4699
Mailing Address - Country:US
Mailing Address - Phone:765-449-2732
Mailing Address - Fax:765-449-1196
Practice Address - Street 1:1411 S CREASY LN
Practice Address - Street 2:SUITE 120
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47905-7438
Practice Address - Country:US
Practice Address - Phone:765-447-4165
Practice Address - Fax:765-447-6978
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2009-10-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
146D00000X
IN10000906A363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No146D00000XEmergency Medical Service ProvidersPersonal Emergency Response Attendant