Provider Demographics
NPI:1558506352
Name:WILSON, TEYONKA T (PA-C)
Entity type:Individual
Prefix:MRS
First Name:TEYONKA
Middle Name:T
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 1:14089 ABERCORN ST
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31419-1966
Mailing Address - Country:US
Mailing Address - Phone:912-350-2121
Mailing Address - Fax:912-350-2145
Practice Address - Street 1:14089 ABERCORN ST
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31419-1966
Practice Address - Country:US
Practice Address - Phone:912-350-2121
Practice Address - Fax:912-350-2145
Is Sole Proprietor?:No
Enumeration Date:2008-12-08
Last Update Date:2014-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA005918363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003125775EMedicaid
GA003125775DMedicaid
GA003125775BMedicaid
GA003125775CMedicaid
GAP01292129OtherRAILROAD MEDICARE
GA202I977444Medicare PIN
GA202I975991Medicare PIN