Provider Demographics
NPI:1194016857
Name:WILSON, NANCY JOANN (PA PHYSICIAN ASSIS)
Entity type:Individual
Prefix:MS
First Name:NANCY
Middle Name:JOANN
Last Name:WILSON
Suffix:
Gender:F
Credentials:PA PHYSICIAN ASSIS
Other - Prefix:MS
Other - First Name:NANCY
Other - Middle Name:WILSON
Other - Last Name:PRINDLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2311 W. MORRISON AVE #27
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33629
Mailing Address - Country:US
Mailing Address - Phone:800-893-9698
Mailing Address - Fax:
Practice Address - Street 1:3838 W. NEPTUNE ST
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33629
Practice Address - Country:US
Practice Address - Phone:800-893-9698
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-28
Last Update Date:2021-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9105925363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant