Provider Demographics
NPI:1710904305
Name:WILSON, ANITA D (FNP)
Entity Type:Individual
Prefix:MS
First Name:ANITA
Middle Name:D
Last Name:WILSON
Suffix:
Gender:F
Credentials:FNP
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 60352
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63160-0352
Mailing Address - Country:US
Mailing Address - Phone:314-362-8200
Mailing Address - Fax:314-454-5244
Practice Address - Street 1:11155 DUNN RD
Practice Address - Street 2:DIV SURG UROLOGY, STE 202N
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63136-6150
Practice Address - Country:US
Practice Address - Phone:314-362-8200
Practice Address - Fax:314-454-5244
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO126493363L00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO427561212Medicaid
MO427561204Medicaid
MO854900OtherHEALTHLINK
MO11752206OtherCAQH
MOAPPLYING INSTACLINICMedicare PIN
MOQ60164Medicare UPIN
MO828484748 (ER CNE)Medicare PIN