Provider Demographics
NPI:1316698582
Name:WILSON, CARLY ANNE (PA)
Entity type:Individual
Prefix:
First Name:CARLY ANNE
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:CARLY
Other - Middle Name:ANNE
Other - Last Name:CASTO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:40 BALL DIAMOND TRL
Mailing Address - Street 2:
Mailing Address - City:VESUVIUS
Mailing Address - State:VA
Mailing Address - Zip Code:24483-2901
Mailing Address - Country:US
Mailing Address - Phone:540-421-0578
Mailing Address - Fax:
Practice Address - Street 1:25 COMMERCE PARK DR
Practice Address - Street 2:
Practice Address - City:RAPHINE
Practice Address - State:VA
Practice Address - Zip Code:24472-2547
Practice Address - Country:US
Practice Address - Phone:540-490-2527
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-10
Last Update Date:2022-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110008398363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant