Provider Demographics
NPI:1467403956
Name:WILSON, CLEMENTE (PA)
Entity Type:Individual
Prefix:DR
First Name:CLEMENTE
Middle Name:
Last Name:WILSON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8750 NW 36TH ST STE 300
Mailing Address - Street 2:
Mailing Address - City:DORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33178-2499
Mailing Address - Country:US
Mailing Address - Phone:305-262-1610
Mailing Address - Fax:
Practice Address - Street 1:900 W 49TH ST STE 308
Practice Address - Street 2:
Practice Address - City:HIALEAH
Practice Address - State:FL
Practice Address - Zip Code:33012-3435
Practice Address - Country:US
Practice Address - Phone:305-266-2929
Practice Address - Fax:305-558-9039
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-12
Last Update Date:2017-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9100865363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPA9100865OtherPHYSICIAN ASSISTANT
FLU1683Medicare ID - Type Unspecified