Provider Demographics
NPI:1720046584
Name:WILSON, PATTY J (CPNP)
Entity Type:Individual
Prefix:
First Name:PATTY
Middle Name:J
Last Name:WILSON
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2608 KYLAY LN
Mailing Address - Street 2:
Mailing Address - City:BUFORD
Mailing Address - State:GA
Mailing Address - Zip Code:30519-7962
Mailing Address - Country:US
Mailing Address - Phone:678-546-6827
Mailing Address - Fax:678-546-6827
Practice Address - Street 1:1001 JOHNSON FERRY RD NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-1605
Practice Address - Country:US
Practice Address - Phone:678-344-1960
Practice Address - Fax:404-785-4969
Is Sole Proprietor?:No
Enumeration Date:2006-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAR103701363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00837493BMedicare ID - Type Unspecified