Provider Demographics
NPI:1114275153
Name:WILSON, ELIZABETH (ARNP)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 25487
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34277-2487
Mailing Address - Country:US
Mailing Address - Phone:941-202-5342
Mailing Address - Fax:
Practice Address - Street 1:4401 CORTEZ RD W
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34210-3142
Practice Address - Country:US
Practice Address - Phone:941-357-5550
Practice Address - Fax:941-792-7152
Is Sole Proprietor?:No
Enumeration Date:2012-08-23
Last Update Date:2017-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF306158-1363LA2200X
FLARNP9433714363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL019547200Medicaid