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General NPI Number Information
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NPI Number | 1912936436
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Entity Type | Individual
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Provider Name | JAMES E WILSON PA-C
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Gender | Male
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Dates
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Enumeration Date | 06/30/2006
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Last Update Date | 11/18/2024
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Provider Practice Location Address
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Address Line | 513 NW LAKE WHITNEY PL STE 101
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City | PORT ST LUCIE
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State | FL
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Zip | 34986-1618
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Country | US
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Telephone | 772-344-7228
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Fax | 772-344-7158
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Provider Business Mailing Address
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Address Line | 513 NW LAKE WHITNEY PL STE 101
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City | PORT ST LUCIE
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State | FL
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Zip | 34986-1618
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Country | US
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Telephone | 772-344-7228
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Fax | 772-344-7158
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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 | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | PA9102360
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License Number State | FL
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