Provider Demographics
NPI:1558363275
Name:WILSON, LISA A (PA-C)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:A
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 1:1061 HARMON AVE. STE 1D03
Mailing Address - Street 2:
Mailing Address - City:FT. STEWART
Mailing Address - State:GA
Mailing Address - Zip Code:31314-5674
Mailing Address - Country:US
Mailing Address - Phone:912-435-5595
Mailing Address - Fax:912-435-5646
Practice Address - Street 1:1061 HARMON AVE DEPT GENERAL
Practice Address - Street 2:
Practice Address - City:FORT STEWART
Practice Address - State:GA
Practice Address - Zip Code:31314-5641
Practice Address - Country:US
Practice Address - Phone:912-435-5595
Practice Address - Fax:912-435-6305
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2023-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003755363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA753648566AMedicaid
GA97WCFHCMedicare ID - Type Unspecified
GA753648566AMedicaid