Healthcare Provider Details

I. General information

NPI: 1215955349
Provider Name (Legal Business Name): EVE WILSON PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2006
Last Update Date: 04/16/2026
Certification Date: 04/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 NICOLLS RD HSC T17-040
STONY BROOK NY
11794-8172
US

IV. Provider business mailing address

301 E MAIN ST HSC T17-040
STONY BROOK NY
11794-8172
US

V. Phone/Fax

Practice location:
  • Phone: 631-444-7790
  • Fax: 631-444-7502
Mailing address:
  • Phone: 631-444-7790
  • Fax: 631-444-7502

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number007322
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: