Healthcare Provider Details

I. General information

NPI: 1982248126
Provider Name (Legal Business Name): DANIELLE K WILSON PHYSICIAN ASSISTANT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/31/2019
Last Update Date: 08/06/2026
Certification Date: 08/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15564 WESTCHESTER COMMONS WAY
MIDLOTHIAN VA
23113-7321
US

IV. Provider business mailing address

PO BOX 715868
PHILADELPHIA PA
19171-5868
US

V. Phone/Fax

Practice location:
  • Phone: 804-440-4878
  • Fax: 804-423-2451
Mailing address:
  • Phone: 804-915-1910
  • Fax: 804-968-1803

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110007882
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10005132A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: