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General NPI Number Information
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NPI Number | 1174006035
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Entity Type | Individual
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Provider Name | TARA NICOLE WILSON PA-C
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Gender | Female
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Dates
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Enumeration Date | 09/07/2018
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Last Update Date | 06/24/2025
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Provider Practice Location Address
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Address Line | 110 IRVING SREET NW ROOM 4B-42
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City | WASHINGTON
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State | DC
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Zip | 20010-2975
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Country | US
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Telephone | 724-831-6122
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Fax |
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Provider Business Mailing Address
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Address Line | 423 E BEAVER ST
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City | ZELIENOPLE
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State | PA
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Zip | 16063-1201
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Country | US
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Telephone | 724-831-6122
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 0010-11443
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License Number State | NC
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