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General NPI Number Information
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NPI Number | 1235688300
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Entity Type | Individual
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Provider Name | STEPHANIE CAROLINE WILSON PA-C
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Gender | Female
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Dates
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Enumeration Date | 09/29/2016
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Last Update Date | 02/13/2017
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Provider Practice Location Address
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Address Line | 1551 PROFESSIONAL LN SUITE 220
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City | LONGMONT
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State | CO
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Zip | 80501-6972
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Country | US
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Telephone | 720-279-9098
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Fax |
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Provider Business Mailing Address
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Address Line | 1551 PROFESSIONAL LN SUITE 220
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City | LONGMONT
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State | CO
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Zip | 80501-6972
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Country | US
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Telephone | 720-279-9098
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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 | PA.0004711
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License Number State | CO
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