Provider Demographics
NPI:1639860562
Name:WILSON, ABIGAIL (PA-C)
Entity Type:Individual
Prefix:
First Name:ABIGAIL
Middle Name:
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 1:1091 DEER LN
Mailing Address - Street 2:
Mailing Address - City:BROOKVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:15825-4715
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:90 BEAVER DR STE 122D
Practice Address - Street 2:
Practice Address - City:DU BOIS
Practice Address - State:PA
Practice Address - Zip Code:15801-2441
Practice Address - Country:US
Practice Address - Phone:814-375-2037
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-19
Last Update Date:2023-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA064592363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant