Provider Demographics
NPI:1578122834
Name:WILSON, JULIE ANN (PA-C)
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:ANN
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 1:1501 W ROGERS BLVD
Mailing Address - Street 2:
Mailing Address - City:SKIATOOK
Mailing Address - State:OK
Mailing Address - Zip Code:74070-3924
Mailing Address - Country:US
Mailing Address - Phone:918-396-4122
Mailing Address - Fax:918-403-6301
Practice Address - Street 1:112 N 5TH ST
Practice Address - Street 2:
Practice Address - City:BARNSDALL
Practice Address - State:OK
Practice Address - Zip Code:74002-6616
Practice Address - Country:US
Practice Address - Phone:918-847-2558
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-11
Last Update Date:2019-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3049363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical