Provider Demographics
NPI:1043706146
Name:WILSON, JONATHAN D (FNP)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:D
Last Name:WILSON
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5546
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80217-5546
Mailing Address - Country:US
Mailing Address - Phone:801-475-3481
Mailing Address - Fax:801-397-6151
Practice Address - Street 1:3225 W GORDON AVE STE 1
Practice Address - Street 2:
Practice Address - City:LAYTON
Practice Address - State:UT
Practice Address - Zip Code:84041-5728
Practice Address - Country:US
Practice Address - Phone:801-397-6150
Practice Address - Fax:801-397-6151
Is Sole Proprietor?:No
Enumeration Date:2018-07-02
Last Update Date:2018-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6496499-4405363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTPENDINGMedicaid