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General NPI Number Information
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NPI Number | 1982248126
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Entity Type | Individual
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Provider Name | DANIELLE K WILSON PHYSICIAN ASSISTANT
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Gender | Female
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Dates
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Enumeration Date | 10/31/2019
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Last Update Date | 01/13/2026
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Provider Practice Location Address
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Address Line | 100 NAVARRE PL STE 4440
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City | SOUTH BEND
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State | IN
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Zip | 46601-1171
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Country | US
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Telephone | 574-647-3725
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Fax |
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Provider Business Mailing Address
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Address Line | 3245 HEALTH DR STE 100
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City | GRANGER
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State | IN
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Zip | 46530-1380
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Country | US
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Telephone | 574-647-3725
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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 | 363AS0400X
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Taxonomy Name | Surgical Physician Assistant
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License Number | 0110-007882
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License Number State | VA
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Taxonomy #2
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 1982248126
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License Number State | IN
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