Provider Demographics
NPI:1114001237
Name:WILSON, SHERESA (PA-C)
Entity Type:Individual
Prefix:
First Name:SHERESA
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:SHERESA
Other - Middle Name:
Other - Last Name:WILSON-DEVRIES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:16311 PAGE RD
Mailing Address - Street 2:
Mailing Address - City:GRABILL
Mailing Address - State:IN
Mailing Address - Zip Code:46741-9612
Mailing Address - Country:US
Mailing Address - Phone:260-452-6700
Mailing Address - Fax:
Practice Address - Street 1:300 E CHICAGO ST STE 200
Practice Address - Street 2:
Practice Address - City:COLDWATER
Practice Address - State:MI
Practice Address - Zip Code:49036-1688
Practice Address - Country:US
Practice Address - Phone:517-279-5378
Practice Address - Fax:517-279-5259
Is Sole Proprietor?:No
Enumeration Date:2006-10-25
Last Update Date:2021-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601005190363A00000X
IN10000892A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q78397Medicare UPIN