Healthcare Provider Details

I. General information

NPI: 1073439956
Provider Name (Legal Business Name): DEVAN CLARE WILSON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/25/2026
Last Update Date: 06/25/2026
Certification Date: 06/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 1ST AVE
NEW YORK NY
10016-6402
US

IV. Provider business mailing address

37 S MERION AVE
BRYN MAWR PA
19010-3202
US

V. Phone/Fax

Practice location:
  • Phone: 212-263-7300
  • Fax:
Mailing address:
  • Phone: 415-577-2668
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: