Healthcare Provider Details

I. General information

NPI: 1033394150
Provider Name (Legal Business Name): JEROMY GLENN WILSON P.A.-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/08/2008
Last Update Date: 11/16/2023
Certification Date: 11/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3520 W 92ND AVE
WESTMINSTER CO
80031-3303
US

IV. Provider business mailing address

6080 W 92ND AVE SUITE 1000
WESTMINSTER CO
80031-2928
US

V. Phone/Fax

Practice location:
  • Phone: 303-429-6600
  • Fax: 303-429-6601
Mailing address:
  • Phone: 303-427-0796
  • Fax: 303-429-9399

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA-2560
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: