Provider Demographics
NPI:1225175516
Name:WILSON, KAREN EVONNE (MS, RD, PA-C)
Entity Type:Individual
Prefix:
First Name:KAREN
Middle Name:EVONNE
Last Name:WILSON
Suffix:
Gender:F
Credentials:MS, RD, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 S CASCADE AVE STE 140
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80903-1604
Mailing Address - Country:US
Mailing Address - Phone:719-538-2900
Mailing Address - Fax:719-538-2990
Practice Address - Street 1:8890 N UNION BLVD STE 220
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80920-2701
Practice Address - Country:US
Practice Address - Phone:719-574-9191
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2024-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA.0004345363A00000X
133VN1004X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Pediatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO53878841Medicaid