Healthcare Provider Details

I. General information

NPI: 1780951913
Provider Name (Legal Business Name): ELIZABETH ARDITH WILSON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/16/2011
Last Update Date: 03/14/2025
Certification Date: 03/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2204 EASTLAND DR
BLOOMINGTON IL
61704-3567
US

IV. Provider business mailing address

611 W PARK FAPC
URBANA IL
61801
US

V. Phone/Fax

Practice location:
  • Phone: 309-661-6900
  • Fax: 309-661-6991
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number085-004145
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085004145
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: