Provider Demographics
NPI:1669007357
Name:GILSON, ELIZABETH ALICE (PA-C)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:ALICE
Last Name:GILSON
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 1:123 HOSPITAL DR STE 1008
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:WI
Mailing Address - Zip Code:53098-3320
Mailing Address - Country:US
Mailing Address - Phone:920-206-6500
Mailing Address - Fax:
Practice Address - Street 1:123 HOSPITAL DR STE 1008
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:WI
Practice Address - Zip Code:53098-3320
Practice Address - Country:US
Practice Address - Phone:920-206-6500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-03
Last Update Date:2021-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WI5149-23363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI10014061Medicaid