Provider Demographics
NPI:1144790866
Name:WILSON, ASHLEY MARIE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:ASHLEY
Middle Name:MARIE
Last Name:WILSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ASHLEY
Other - Middle Name:MARIE
Other - Last Name:OVERBY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:43 2ND AVE SE APT 201
Mailing Address - Street 2:
Mailing Address - City:FOREST LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55025-1657
Mailing Address - Country:US
Mailing Address - Phone:715-566-1090
Mailing Address - Fax:
Practice Address - Street 1:5525 CEDAR LAKE RD S
Practice Address - Street 2:
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416-1420
Practice Address - Country:US
Practice Address - Phone:952-541-7157
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-26
Last Update Date:2021-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN12844363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant