Provider Demographics
NPI:1316210131
Name:WILSON, DANIEL MARK JR (RPA-C)
Entity Type:Individual
Prefix:MR
First Name:DANIEL
Middle Name:MARK
Last Name:WILSON
Suffix:JR
Gender:M
Credentials:RPA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:20 MALLARD RD
Mailing Address - Street 2:
Mailing Address - City:LEVITTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11756-4204
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1000 MONTAUK HWY
Practice Address - Street 2:
Practice Address - City:WEST ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11795-4927
Practice Address - Country:US
Practice Address - Phone:631-376-4444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-10
Last Update Date:2012-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015362-1363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical