Provider Demographics
NPI:1235258443
Name:WILSON, JOSEPH A SR (PA)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:A
Last Name:WILSON
Suffix:SR
Gender:M
Credentials:PA
Other - Prefix:
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Other - Last Name:
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Mailing Address - Street 1:4780 SW 64TH AVE STE 103
Mailing Address - Street 2:
Mailing Address - City:DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33314-4400
Mailing Address - Country:US
Mailing Address - Phone:954-434-1705
Mailing Address - Fax:954-450-8502
Practice Address - Street 1:2004 N FLAMINGO RD
Practice Address - Street 2:
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33028-3500
Practice Address - Country:US
Practice Address - Phone:954-450-8500
Practice Address - Fax:954-450-8502
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2020-01-13
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
FLPA9101757363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL023533600Medicaid