Provider Demographics
NPI:1114564036
Name:WILSON, JUSTINE K (PA-C)
Entity Type:Individual
Prefix:
First Name:JUSTINE
Middle Name:K
Last Name:WILSON
Suffix:
Gender:F
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 1:217 WILD ONION LN
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76131-2490
Mailing Address - Country:US
Mailing Address - Phone:817-229-6663
Mailing Address - Fax:
Practice Address - Street 1:3645 WESTERN CENTER BLVD
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76137-1944
Practice Address - Country:US
Practice Address - Phone:817-232-9767
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-10
Last Update Date:2022-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant