Provider Demographics
NPI:1023366887
Name:WILSON, ANDY (ARNP)
Entity Type:Individual
Prefix:
First Name:ANDY
Middle Name:
Last Name:WILSON
Suffix:
Gender:M
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:6195 LAKE GRAY BLVD
Mailing Address - Street 2:SUITE 4
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32244-5891
Mailing Address - Country:US
Mailing Address - Phone:904-389-1010
Mailing Address - Fax:904-389-1082
Practice Address - Street 1:1375 ROBERTS DR
Practice Address - Street 2:SUITE 205
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32250-3210
Practice Address - Country:US
Practice Address - Phone:904-389-1010
Practice Address - Fax:904-389-1082
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-27
Last Update Date:2017-02-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLARNP9225092363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily