Provider Demographics
NPI:1821289885
Name:WILSON, JEANINE M (PA-C)
Entity Type:Individual
Prefix:
First Name:JEANINE
Middle Name:M
Last Name:WILSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4549 SPOTSWOOD TRL STE 8
Mailing Address - Street 2:
Mailing Address - City:PENN LAIRD
Mailing Address - State:VA
Mailing Address - Zip Code:22846-2050
Mailing Address - Country:US
Mailing Address - Phone:540-433-8700
Mailing Address - Fax:540-433-8080
Practice Address - Street 1:4549 SPOTSWOOD TRL STE 8
Practice Address - Street 2:
Practice Address - City:PENN LAIRD
Practice Address - State:VA
Practice Address - Zip Code:22846-2050
Practice Address - Country:US
Practice Address - Phone:540-433-8700
Practice Address - Fax:540-433-8080
Is Sole Proprietor?:No
Enumeration Date:2007-08-06
Last Update Date:2022-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110002529363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAVAA101210Medicare PIN