Provider Demographics
NPI:1508151606
Name:WILSON, JENNIFER MICHELLE (PA-C)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:MICHELLE
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 1:6320 W UNION HILLS DR
Mailing Address - Street 2:STE B - 1600
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85308-1096
Mailing Address - Country:US
Mailing Address - Phone:602-357-2400
Mailing Address - Fax:
Practice Address - Street 1:1760 E RIVER RD
Practice Address - Street 2:STE. # 350
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85718-5877
Practice Address - Country:US
Practice Address - Phone:520-519-7775
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-16
Last Update Date:2014-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA-091363AS0400X
AZ5385363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ661364Medicaid
AZZ158888Medicare PIN