Provider Demographics
NPI:1659913531
Name:WILSON, ADAM A (APRN)
Entity Type:Individual
Prefix:
First Name:ADAM
Middle Name:A
Last Name:WILSON
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:132 MOULTRIE CROSSING LN
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32086-5242
Mailing Address - Country:US
Mailing Address - Phone:904-687-8964
Mailing Address - Fax:
Practice Address - Street 1:132 MOULTRIE CROSSING LN
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-5242
Practice Address - Country:US
Practice Address - Phone:904-687-8964
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-12
Last Update Date:2020-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11004458363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL104733000Medicaid