MEDICARE: JENNIFER MICHELLE WILSON PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AS0400X	Surgical Physician Assistant	PA-091	NM
2	363AM0700X	Medical Physician Assistant	5385	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1508151606
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNIFER MICHELLE WILSON PA-C

Provider Business Mailing Address
First Line	:	6320 W UNION HILLS DR
Second Line	:	STE B - 1600
City	:	GLENDALE
State	:	AZ
Zip	:	85308-1096
Country	:	US
Telephone Number	:	602-357-2400
Fax Number	:

Provider Business Practice Location Address
First Line	:	1760 E RIVER RD
Second Line	:	STE. # 350
City	:	TUCSON
State	:	AZ
Zip	:	85718-5877
Country	:	US
Telephone Number	:	520-519-7775
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/16/2011
Last Update Date	:	01/31/2014

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