Provider Demographics
NPI:1124318027
Name:WILSON, KELLY L (PA-C)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:L
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 1:5030 J ST
Mailing Address - Street 2:STE 201
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95819-3800
Mailing Address - Country:US
Mailing Address - Phone:916-455-1155
Mailing Address - Fax:
Practice Address - Street 1:5030 J ST
Practice Address - Street 2:STE 201
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95819-3800
Practice Address - Country:US
Practice Address - Phone:916-455-1155
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-12
Last Update Date:2017-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA21542363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical