Provider Demographics
NPI:1720563984
Name:WILSON, SAVANNAH LEA (PA)
Entity Type:Individual
Prefix:
First Name:SAVANNAH
Middle Name:LEA
Last Name:WILSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:SAVANNAH
Other - Middle Name:LEA
Other - Last Name:LOWRY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2101 N WALDRON ST
Mailing Address - Street 2:
Mailing Address - City:HUTCHINSON
Mailing Address - State:KS
Mailing Address - Zip Code:67502-1197
Mailing Address - Country:US
Mailing Address - Phone:620-669-2500
Mailing Address - Fax:206-944-1806
Practice Address - Street 1:2101 N WALDRON ST
Practice Address - Street 2:
Practice Address - City:HUTCHINSON
Practice Address - State:KS
Practice Address - Zip Code:67502-1131
Practice Address - Country:US
Practice Address - Phone:620-694-4194
Practice Address - Fax:620-694-2128
Is Sole Proprietor?:No
Enumeration Date:2018-10-03
Last Update Date:2021-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS15-02130363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant