Provider Demographics
NPI:1326718701
Name:WILSON, ANNE JANETTE (PA-C)
Entity Type:Individual
Prefix:
First Name:ANNE
Middle Name:JANETTE
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 1:1449 RUNGE AVE
Mailing Address - Street 2:
Mailing Address - City:BLAINE
Mailing Address - State:WA
Mailing Address - Zip Code:98230-9507
Mailing Address - Country:US
Mailing Address - Phone:970-402-7988
Mailing Address - Fax:
Practice Address - Street 1:1201 PACIFIC AVE STE 400
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98402-4381
Practice Address - Country:US
Practice Address - Phone:970-402-7988
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-16
Last Update Date:2021-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61224506363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA61224506OtherSTATE TEMPORARY LICENSE