Provider Demographics
NPI:1962707182
Name:WILSON, HOLLY (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:
First Name:HOLLY
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:919 COUNTRY RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65109-5738
Mailing Address - Country:US
Mailing Address - Phone:573-690-3390
Mailing Address - Fax:
Practice Address - Street 1:800 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-5275
Practice Address - Country:US
Practice Address - Phone:573-814-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-19
Last Update Date:2011-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110002870363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical