Provider Demographics
NPI:1568454940
Name:WILSON, SHERI A (PA-C)
Entity Type:Individual
Prefix:
First Name:SHERI
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 1:516 WINDY CT
Mailing Address - Street 2:
Mailing Address - City:KOKOMO
Mailing Address - State:IN
Mailing Address - Zip Code:46901-3703
Mailing Address - Country:US
Mailing Address - Phone:269-240-7300
Mailing Address - Fax:
Practice Address - Street 1:1245 E IRELAND RD
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46614-3448
Practice Address - Country:US
Practice Address - Phone:743-127-0225
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-22
Last Update Date:2018-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10000582A363A00000X
MI5601004689363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant