Provider Demographics
NPI:1760453021
Name:WILSON, SHAWNA (ANPC)
Entity Type:Individual
Prefix:
First Name:SHAWNA
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:ANPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3801 UNIVERSITY LAKE DR
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508-4639
Mailing Address - Country:US
Mailing Address - Phone:907-563-8876
Mailing Address - Fax:907-762-6315
Practice Address - Street 1:3801 UNIVERSITY LAKE DR
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-4639
Practice Address - Country:US
Practice Address - Phone:907-563-8876
Practice Address - Fax:907-762-6315
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK575363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKNP8017Medicaid
AK151906Medicare ID - Type Unspecified
AKNP8017Medicaid