Provider Demographics
NPI:1659329951
Name:WILSON, DEAN JR (PA)
Entity Type:Individual
Prefix:MR
First Name:DEAN
Middle Name:
Last Name:WILSON
Suffix:JR
Gender:M
Credentials:PA
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 98
Mailing Address - Street 2:
Mailing Address - City:AGOURA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91376-0098
Mailing Address - Country:US
Mailing Address - Phone:818-422-7246
Mailing Address - Fax:
Practice Address - Street 1:7300 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:WEST HILLS
Practice Address - State:CA
Practice Address - Zip Code:91307-1902
Practice Address - Country:US
Practice Address - Phone:818-422-7246
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-05
Last Update Date:2022-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9102460363AS0400X
CAPA19199363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP95621Medicare UPIN
FLU1111ZMedicare ID - Type Unspecified