Provider Demographics
NPI:1003847773
Name:WILSON, ALTHEA NERESSA (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:ALTHEA
Middle Name:NERESSA
Last Name:WILSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ALTHEA
Other - Middle Name:NERESSA
Other - Last Name:TINKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:2160 HOLLAND AVE APT E8
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10462-1730
Mailing Address - Country:US
Mailing Address - Phone:718-794-9340
Mailing Address - Fax:
Practice Address - Street 1:506 6TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11215-3609
Practice Address - Country:US
Practice Address - Phone:718-780-7700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009767363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical