Provider Demographics
NPI:1104544097
Name:WILSON, CHAR'TARIAN (PA)
Entity type:Individual
Prefix:
First Name:CHAR'TARIAN
Middle Name:
Last Name:WILSON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1514 JEFFERSON HWY
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70121-2429
Mailing Address - Country:US
Mailing Address - Phone:504-842-4000
Mailing Address - Fax:
Practice Address - Street 1:2215 VETERANS MEMORIAL BLVD
Practice Address - Street 2:
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70002-6322
Practice Address - Country:US
Practice Address - Phone:504-838-3524
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-17
Last Update Date:2024-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
CA64500363A00000X
LA333750363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant