Provider Demographics
NPI:1558424614
Name:WILSON, ANDREA LOIS (PA-C)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:LOIS
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 1:9000 N MAIN STREET
Mailing Address - Street 2:SUITE 101
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45415
Mailing Address - Country:US
Mailing Address - Phone:937-832-2425
Mailing Address - Fax:937-832-9804
Practice Address - Street 1:9000 N MAIN STREET
Practice Address - Street 2:SUITE 101
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45415
Practice Address - Country:US
Practice Address - Phone:937-832-2425
Practice Address - Fax:937-832-9804
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2014-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50001937363A00000X
OH50-001937363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0067865Medicaid
OHH079320Medicare PIN
OH0067865Medicaid