Provider Demographics
NPI:1588987010
Name:WILSON, JANET KATHERINE (CPNP)
Entity type:Individual
Prefix:
First Name:JANET
Middle Name:KATHERINE
Last Name:WILSON
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:JANET
Other - Middle Name:ANN
Other - Last Name:IVANY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1301 BARBARA JORDAN BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78723-3078
Mailing Address - Country:US
Mailing Address - Phone:512-628-1850
Mailing Address - Fax:512-628-1851
Practice Address - Street 1:1301 BARBARA JORDAN BLVD STE 200
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78723-3078
Practice Address - Country:US
Practice Address - Phone:512-628-1850
Practice Address - Fax:512-628-1851
Is Sole Proprietor?:No
Enumeration Date:2010-03-11
Last Update Date:2016-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX685812363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX219630501Medicaid
TX8L27095Medicare PIN