Provider Demographics
NPI:1407973027
Name:WILSON, JANET LEAHY (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:JANET
Middle Name:LEAHY
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:PO BOX 743070
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3070
Mailing Address - Country:US
Mailing Address - Phone:864-560-4304
Mailing Address - Fax:864-560-4413
Practice Address - Street 1:101 E WOOD ST
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29303-3040
Practice Address - Country:US
Practice Address - Phone:864-560-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1825363A00000X
NC0010-00422363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC0825PAMedicaid
SCAA99508510OtherMEDICARE PIN
SCAA99509068OtherMEDICARE PIN
SCAA9950H918OtherMEDICARE PIN
SCME 1825OtherPHYSICIAN ASSISTANT LICENSE
SCAA99506067OtherMEDICARE PIN
SCAA9950J577OtherMEDICARE PIN
NC0010-00422OtherNC MEDICAL LICENSE
SCAA99506084OtherMEDICARE PIN
SCAA99506084OtherMEDICARE PIN