Provider Demographics
NPI:1033394150
Name:WILSON, JEROMY GLENN (PA-C)
Entity Type:Individual
Prefix:
First Name:JEROMY
Middle Name:GLENN
Last Name:WILSON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6080 W 92ND AVE
Mailing Address - Street 2:SUITE 1000
Mailing Address - City:WESTMINSTER
Mailing Address - State:CO
Mailing Address - Zip Code:80031-2928
Mailing Address - Country:US
Mailing Address - Phone:303-427-0796
Mailing Address - Fax:303-429-9399
Practice Address - Street 1:3520 W 92ND AVE
Practice Address - Street 2:
Practice Address - City:WESTMINSTER
Practice Address - State:CO
Practice Address - Zip Code:80031-3303
Practice Address - Country:US
Practice Address - Phone:303-429-6600
Practice Address - Fax:303-429-6601
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-08
Last Update Date:2023-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA-2560363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
1080625OtherNCCPA