Healthcare Provider Details

I. General information

NPI: 1144469644
Provider Name (Legal Business Name): WILLIAM JARRETT WILSON APRN, FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/07/2009
Last Update Date: 02/08/2023
Certification Date: 02/08/2023
Deactivation Date: 10/02/2019
Reactivation Date: 10/10/2019

III. Provider practice location address

406 SUNRISE AVE STE 330
ROSEVILLE CA
95661-4106
US

IV. Provider business mailing address

406 SUNRISE AVE STE 330
ROSEVILLE CA
95661-4106
US

V. Phone/Fax

Practice location:
  • Phone: 916-547-8158
  • Fax: 866-390-0008
Mailing address:
  • Phone: 916-547-8158
  • Fax: 866-390-0008

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License Number849311
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95011839
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: