Provider Demographics
NPI:1295019925
Name:WILSON, SHERENE (PA)
Entity Type:Individual
Prefix:
First Name:SHERENE
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4311 SALISBURY RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-6123
Mailing Address - Country:US
Mailing Address - Phone:904-332-4300
Mailing Address - Fax:904-332-4339
Practice Address - Street 1:4311 SALISBURY RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-6123
Practice Address - Country:US
Practice Address - Phone:904-332-4300
Practice Address - Fax:904-332-4339
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-29
Last Update Date:2011-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9106036363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant