Provider Demographics
NPI:1104557206
Name:WILSON, JAMIE IV (APRN)
Entity type:Individual
Prefix:MR
First Name:JAMIE
Middle Name:
Last Name:WILSON
Suffix:IV
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:JAMIE
Other - Middle Name:
Other - Last Name:WILSON
Other - Suffix:IV
Other - Last Name Type:Other Name
Other - Credentials:APRN
Mailing Address - Street 1:1839 CENTRAL AVENUE
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33713-8900
Mailing Address - Country:US
Mailing Address - Phone:727-322-1054
Mailing Address - Fax:727-821-7213
Practice Address - Street 1:1839 CENTRAL AVENUE
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33713-8900
Practice Address - Country:US
Practice Address - Phone:727-322-1054
Practice Address - Fax:727-821-7213
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-20
Last Update Date:2024-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11020316363LF0000X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL119817600Medicaid
FLJXSUEOtherBCBS