Provider Demographics
NPI:1215119466
Name:WILSON, SARA JAIME (PA-C)
Entity type:Individual
Prefix:MRS
First Name:SARA
Middle Name:JAIME
Last Name:WILSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:SARA
Other - Middle Name:JAIME
Other - Last Name:MASTERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:100 MICHIGAN ST NE # MC845
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2560
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7751 BYRON CENTER AVE SW STE A
Practice Address - Street 2:
Practice Address - City:BYRON CENTER
Practice Address - State:MI
Practice Address - Zip Code:49315-8001
Practice Address - Country:US
Practice Address - Phone:616-878-3321
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-29
Last Update Date:2024-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1955363AM0700X
MI5601012418363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical