Provider Demographics
NPI:1073574232
Name:WILSON, GRETCHEN GAY (PA)
Entity Type:Individual
Prefix:
First Name:GRETCHEN
Middle Name:GAY
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 1:10140 ESTATE LANE
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75238
Mailing Address - Country:US
Mailing Address - Phone:972-672-8468
Mailing Address - Fax:
Practice Address - Street 1:10140 ESTATE LANE
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75238
Practice Address - Country:US
Practice Address - Phone:972-672-8468
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-29
Last Update Date:2012-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA03390363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8L11457Medicare PIN
TXP57009Medicare UPIN
TNTXB142376Medicare PIN
TX8969K2Medicare ID - Type Unspecified