Healthcare Provider Details

I. General information

NPI: 1104368042
Provider Name (Legal Business Name): JANAE E WILSON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JANAE E MATZAT PA-C

II. Dates (important events)

Enumeration Date: 11/09/2016
Last Update Date: 01/20/2023
Certification Date: 01/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 GATEWAY BLVD N
CHESTERTON IN
46304-9658
US

IV. Provider business mailing address

601 GATEWAY BLVD N
CHESTERTON IN
46304-9658
US

V. Phone/Fax

Practice location:
  • Phone: 219-921-1444
  • Fax: 219-921-5303
Mailing address:
  • Phone: 219-921-1444
  • Fax: 219-921-5303

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10002160A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: