Provider Demographics
NPI:1912936436
Name:WILSON, JAMES E (PA-C)
Entity type:Individual
Prefix:MR
First Name:JAMES
Middle Name:E
Last Name:WILSON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:513 NW LAKE WHITNEY PL STE 101
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34986-1618
Mailing Address - Country:US
Mailing Address - Phone:772-344-7228
Mailing Address - Fax:772-344-7158
Practice Address - Street 1:513 NW LAKE WHITNEY PL STE 101
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34986-1618
Practice Address - Country:US
Practice Address - Phone:772-344-7228
Practice Address - Fax:772-344-7158
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2024-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9102360363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU0804ZMedicare ID - Type Unspecified
P16923Medicare UPIN