Provider Demographics
NPI:1396826640
Name:WILSON, JASON PAUL (MD)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:PAUL
Last Name:WILSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2995 DREW ST
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33759-3012
Mailing Address - Country:US
Mailing Address - Phone:727-315-7496
Mailing Address - Fax:
Practice Address - Street 1:11803 JEFFERSON AVE STE 235
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23606-2565
Practice Address - Country:US
Practice Address - Phone:757-594-1806
Practice Address - Fax:757-510-9079
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME127549208600000X
VA0101248811208600000X
NY251807208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03101360Medicaid
FL018648100Medicaid
FLIR727ZMedicare PIN
NY03101360Medicaid
NYJ400003592Medicare PIN