Provider Demographics
NPI:1104368042
Name:WILSON, JANAE E (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:JANAE
Middle Name:E
Last Name:WILSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JANAE
Other - Middle Name:E
Other - Last Name:MATZAT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:601 GATEWAY BLVD N
Mailing Address - Street 2:
Mailing Address - City:CHESTERTON
Mailing Address - State:IN
Mailing Address - Zip Code:46304-9658
Mailing Address - Country:US
Mailing Address - Phone:219-921-1444
Mailing Address - Fax:219-921-5303
Practice Address - Street 1:601 GATEWAY BLVD N
Practice Address - Street 2:
Practice Address - City:CHESTERTON
Practice Address - State:IN
Practice Address - Zip Code:46304-9658
Practice Address - Country:US
Practice Address - Phone:219-921-1444
Practice Address - Fax:219-921-5303
Is Sole Proprietor?:No
Enumeration Date:2016-11-09
Last Update Date:2023-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10002160A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant