Provider Demographics
NPI:1619153210
Name:WILSON, JERRY DEWAYNE (PA-C)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:DEWAYNE
Last Name:WILSON
Suffix:
Gender:M
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:PO BOX 360550
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30036-0550
Mailing Address - Country:US
Mailing Address - Phone:678-632-4003
Mailing Address - Fax:678-681-1305
Practice Address - Street 1:4500 HUGH HOWELL RD
Practice Address - Street 2:SUITE
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-4723
Practice Address - Country:US
Practice Address - Phone:678-632-4003
Practice Address - Fax:678-681-1305
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-14
Last Update Date:2010-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003052363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA308036587AMedicaid
GAQ28376Medicare UPIN