Provider Demographics
NPI:1073609442
Name:WILSON, TERRY L (PA-C)
Entity Type:Individual
Prefix:
First Name:TERRY
Middle Name:L
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 1:1299 BISHOP RD
Mailing Address - Street 2:
Mailing Address - City:CHEHALIS
Mailing Address - State:WA
Mailing Address - Zip Code:98532-8758
Mailing Address - Country:US
Mailing Address - Phone:360-748-0211
Mailing Address - Fax:360-748-8732
Practice Address - Street 1:1299 BISHOP RD
Practice Address - Street 2:
Practice Address - City:CHEHALIS
Practice Address - State:WA
Practice Address - Zip Code:98532-8758
Practice Address - Country:US
Practice Address - Phone:360-748-0211
Practice Address - Fax:360-748-8732
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2023-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10000075363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0134911OtherLABOR & INDUSTRIES
WA9112WIOtherREGENCE
970011631OtherRAILROAD MEDICARE
G8806697Medicare PIN
S49230Medicare UPIN