Provider Demographics
NPI:1063491223
Name:WILSON, PAMELA S (PA)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:S
Last Name:WILSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:457-B HWY 123 BYPASS
Mailing Address - Street 2:
Mailing Address - City:SENECA
Mailing Address - State:SC
Mailing Address - Zip Code:29678-0842
Mailing Address - Country:US
Mailing Address - Phone:864-888-4464
Mailing Address - Fax:864-888-4462
Practice Address - Street 1:457-B HWY 123 BYPASS
Practice Address - Street 2:
Practice Address - City:SENECA
Practice Address - State:SC
Practice Address - Zip Code:29678-0842
Practice Address - Country:US
Practice Address - Phone:864-888-4464
Practice Address - Fax:864-888-4462
Is Sole Proprietor?:No
Enumeration Date:2006-01-16
Last Update Date:2012-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCA632363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCRHC195Medicaid
SCGP1060Medicaid