Provider Demographics
NPI:1588915425
Name:WILSON, EDWARD S (CSA)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:S
Last Name:WILSON
Suffix:
Gender:
Credentials:CSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:604 BISHOP DR
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23455-6544
Mailing Address - Country:US
Mailing Address - Phone:757-672-3738
Mailing Address - Fax:757-499-2295
Practice Address - Street 1:604 BISHOP DR
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23455
Practice Address - Country:US
Practice Address - Phone:757-672-3738
Practice Address - Fax:757-499-2295
Is Sole Proprietor?:No
Enumeration Date:2012-10-01
Last Update Date:2025-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0136000040246ZC0007X
363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant