Healthcare Provider Details

I. General information

NPI: 1063193126
Provider Name (Legal Business Name): SARA JANELLE WILSON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/31/2023
Last Update Date: 09/05/2023
Certification Date: 09/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 PETER JEFFERSON PKWY STE 310
CHARLOTTESVILLE VA
22911-8836
US

IV. Provider business mailing address

3200 VANTAGE WAY APT 111
CROZET VA
22932-3197
US

V. Phone/Fax

Practice location:
  • Phone: 434-977-0027
  • Fax:
Mailing address:
  • Phone: 540-820-2061
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number0110009445
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: