Provider Demographics
NPI:1235353988
Name:WILSON, KATHERINE ANN (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:KATHERINE
Middle Name:ANN
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:PO BOX 746638
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-6638
Mailing Address - Country:US
Mailing Address - Phone:904-202-1032
Mailing Address - Fax:904-376-4107
Practice Address - Street 1:30 ARDISIA LANE
Practice Address - Street 2:
Practice Address - City:ST. JOHNS
Practice Address - State:FL
Practice Address - Zip Code:32259
Practice Address - Country:US
Practice Address - Phone:904-287-2794
Practice Address - Fax:904-390-7458
Is Sole Proprietor?:No
Enumeration Date:2007-04-12
Last Update Date:2022-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA005035363A00000X
FLPA9104552363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA411072211AMedicaid
Q78758Medicare UPIN
FLFN251ZMedicare PIN
GA97WCJPXMedicare ID - Type Unspecified