Provider Demographics
NPI:1275659401
Name:WILSON, JAMES ANTHONY (PA)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:ANTHONY
Last Name:WILSON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4819 CORBINA WAY
Mailing Address - Street 2:
Mailing Address - City:OXNARD
Mailing Address - State:CA
Mailing Address - Zip Code:93035-2810
Mailing Address - Country:US
Mailing Address - Phone:805-469-4343
Mailing Address - Fax:
Practice Address - Street 1:5601 DE SOTO AVE
Practice Address - Street 2:
Practice Address - City:WOODLAND HILLS
Practice Address - State:CA
Practice Address - Zip Code:91367-6701
Practice Address - Country:US
Practice Address - Phone:818-719-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-21
Last Update Date:2013-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA11508363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
S42310Medicare UPIN