Provider Demographics
NPI:1215373808
Name:WILSON, KATHRYN (PA-C)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:
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 1:5201 N 19TH AVE
Mailing Address - Street 2:SUITE 121
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85015-2951
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5201 N 19TH AVE
Practice Address - Street 2:SUITE 121
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85015-2951
Practice Address - Country:US
Practice Address - Phone:602-433-1882
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-22
Last Update Date:2013-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant