Provider Demographics
NPI:1821336306
Name:WILSON, JASON P (PA)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:P
Last Name:WILSON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1430
Mailing Address - Street 2:
Mailing Address - City:HARRISONBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22803-1430
Mailing Address - Country:US
Mailing Address - Phone:540-689-5500
Mailing Address - Fax:757-431-7116
Practice Address - Street 1:2509 PLEASANT RUN DR
Practice Address - Street 2:
Practice Address - City:ROCKINGHAM
Practice Address - State:VA
Practice Address - Zip Code:22801-8720
Practice Address - Country:US
Practice Address - Phone:540-689-5500
Practice Address - Fax:757-431-7116
Is Sole Proprietor?:No
Enumeration Date:2013-01-18
Last Update Date:2020-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
VA0110004140363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1821336306Medicaid