MEDICARE: SHERESA WILSON PA-C LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0800X	Psychiatry Physician

General Provider Information

NPI Number	:	1528865177
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SHERESA WILSON PA-C LLC

Provider Business Mailing Address
First Line	:	419 AIRPORT NORTH OFFICE PARK
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46825-6704
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	419 AIRPORT NORTH OFFICE PARK
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46825-6704
Country	:	US
Telephone Number	:	260-452-6700
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	SHERESA WILSON
Credential	:
Telephone Number	:	260-452-6700

Provider Enumeration Date	:	02/28/2025
Last Update Date	:	02/28/2025

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