Provider Demographics
NPI:1124102991
Name:WILSON, RAELEEN ALISE (PA)
Entity type:Individual
Prefix:
First Name:RAELEEN
Middle Name:ALISE
Last Name:WILSON
Suffix:
Gender:F
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:PO BOX 16948
Mailing Address - Street 2:
Mailing Address - City:ASHEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28816-0948
Mailing Address - Country:US
Mailing Address - Phone:828-670-8403
Mailing Address - Fax:828-670-8404
Practice Address - Street 1:100 RIDGEFIELD CT
Practice Address - Street 2:
Practice Address - City:ASHEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28806-2207
Practice Address - Country:US
Practice Address - Phone:828-670-8403
Practice Address - Fax:828-670-8404
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC103815363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCP97631Medicare UPIN
NC2759386Medicare ID - Type Unspecified