Provider Demographics
NPI:1497030076
Name:WILSON, CASSANDRA D (PA - C)
Entity Type:Individual
Prefix:
First Name:CASSANDRA
Middle Name:D
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 936
Mailing Address - Street 2:EVMS HEALTH SERVICES
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23501-0936
Mailing Address - Country:US
Mailing Address - Phone:757-446-8999
Mailing Address - Fax:757-446-7922
Practice Address - Street 1:825 FAIRFAX AVE
Practice Address - Street 2:SUITE 545
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23507-1914
Practice Address - Country:US
Practice Address - Phone:757-446-8999
Practice Address - Fax:757-446-7922
Is Sole Proprietor?:No
Enumeration Date:2011-10-14
Last Update Date:2013-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110004025363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1497030076Medicaid
VA-032OtherTRICARE/CHAMPUS
NC8102983Medicaid
VAPAROtherUSA MANAGED CARE
VA10102992POtherOPTIMA HEALTH
VAPAROtherCORVEL
VAPAROtherMULTIPLAN
VA1497030076Medicaid