Provider Demographics
NPI:1790730653
Name:WILSON, MAVIS CASINER (NP)
Entity Type:Individual
Prefix:MS
First Name:MAVIS
Middle Name:CASINER
Last Name:WILSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1720 S GADSDEN ST
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32301-5506
Mailing Address - Country:US
Mailing Address - Phone:850-576-4073
Mailing Address - Fax:850-521-5116
Practice Address - Street 1:1720 S GADSDEN ST
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32301-5506
Practice Address - Country:US
Practice Address - Phone:904-248-4075
Practice Address - Fax:904-223-3149
Is Sole Proprietor?:No
Enumeration Date:2006-05-22
Last Update Date:2013-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9222827363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLS83911Medicare UPIN
FLU7705YMedicare PIN