Healthcare Provider Details

I. General information

NPI: 1831160332
Provider Name (Legal Business Name): DANIEL G WILSON PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/01/2006
Last Update Date: 11/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1821 BLANDING BLVD SUITE 1
MIDDLEBURG FL
32068-3839
US

IV. Provider business mailing address

PO BOX 850001
ORLANDO FL
32885-0192
US

V. Phone/Fax

Practice location:
  • Phone: 904-406-3160
  • Fax: 904-406-3159
Mailing address:
  • Phone: 904-282-6331
  • Fax: 904-282-4117

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA2944
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: